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Evaluation of Cervical Spine Injuries

  • Ajay Malhotra
  • Ajai K. MalhotraEmail author
Trauma to the Neck (W Biffl, Section Editor)
  • 3 Downloads
Part of the following topical collections:
  1. Topical Collection on Trauma to the Neck

Abstract

Purpose of Review

Critically evaluate the current evidence in evaluation of the cervical spine following trauma.

Recent Findings

Little has changed in the evaluation of the cervical spine following penetrating trauma. Significant advances have been made in the evaluation following blunt trauma. Recent research has focused on evaluating the accuracy of recent generation-computed tomographic (CT) scanners in excluding (or identifying) significant cervical spine injury. Secondly, recent literature has evaluated the utility of magnetic resonance imaging (MRI) in the evaluation of the cervical spine injury following blunt trauma.

Summary

Current evidence supports (1) in an adult patient if a high-quality CT scan, interpreted by a trained neuro-radiologist, does not demonstrate any abnormal findings, significant cervical spine injury can be excluded and the collar safely removed; (2) MRI adds little to the evaluation if the CT scan is negative; and (3) MRI scan is helpful if a CT is equivocal or to plan therapy when the CT demonstrates injury.

Keywords

Cervical spine Trauma Evaluation Imaging MRI 

Notes

Compliance with Ethical Standards

Conflict of Interest

The authors declare no conflicts of interest relevant to this manuscript.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Grogan EL, Morris JA Jr, Dittus RS, Moore DE, Poulose BK, Diaz JJ, et al. Cervical spine evaluation in urban trauma centers: lowering institutional costs and complications through helical CT scan. J Am Coll Surg. 2005;200:160–5.CrossRefGoogle Scholar
  2. 2.
    Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. 2000;343:94–9.CrossRefGoogle Scholar
  3. 3.
    Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001;286:1841–8.CrossRefGoogle Scholar
  4. 4.
    Duane TM, Mayglothling J, Wilson SP, Wolfe LG, Aboutanos MB, Whelan JF, et al. National Emergency X-radiography utilization study criteria is inadequate to rule out fracture after significant blunt trauma compared with computed tomography. J Trauma. 2011;70:829–31.CrossRefGoogle Scholar
  5. 5.
    Duane TM, Wilson SP, Mayglothling J, Wolfe LG, Aboutanos MB, Whelan JF, et al. Canadian cervical spine rule compared with computed tomography: a prospective analysis. J Trauma. 2011;71:352–5. discussion 355-357.CrossRefGoogle Scholar
  6. 6.
    Davis JW, Kaups KL, Cunningham MA, Parks SN, Nowak TP, Bilello JF, et al. Routine evaluation of the cervical spine in head-injured patients with dynamic fluoroscopy: a reappraisal. J Trauma. 2001;50:1044–7.CrossRefGoogle Scholar
  7. 7.
    • Malhotra A, Wu X, Kalra VB, Nardini HK, Liu R, Abbed KM, et al. Utility of MRI for cervical spine clearance after blunt traumatic injury: a meta-analysis. Eur Radiol. 2017;27:1148–60 Meta-analysis showing limited utility of MRI in detecting unstable injury in patients with a negative CT scan. CrossRefGoogle Scholar
  8. 8.
    Muchow RD, Resnick DK, Abdel MP, Munoz A, Anderson PA. Magnetic resonance imaging (MRI) in the clearance of the cervical spine in blunt trauma: a meta-analysis. J Trauma. 2008;64:179–89.CrossRefGoogle Scholar
  9. 9.
    Schoenfeld AJ, Bono CM, McGuire KJ, Warholic N, Harris MB. Computed tomography alone versus computed tomography and magnetic resonance imaging in the identification of occult injuries to the cervical spine: a meta-analysis. J Trauma. 2010;68:109–13. discussion 113–104.CrossRefGoogle Scholar
  10. 10.
    Russin JJ, Attenello FJ, Amar AP, Liu CY, Apuzzo ML, Hsieh PC. Computed tomography for clearance of cervical spine injury in the unevaluable patient. World Neurosurg. 2013;80:405–13.CrossRefGoogle Scholar
  11. 11.
    James IA, Moukalled A, Yu E, Tulman DB, Bergese SD, Jones CD, et al. A systematic review of the need for MRI for the clearance of cervical spine injury in obtunded blunt trauma patients after normal cervical spine CT. J Emerg Trauma Shock. 2014;7:251–5.CrossRefGoogle Scholar
  12. 12.
    Panczykowski DM, Tomycz ND, Okonkwo DO. Comparative effectiveness of using computed tomography alone to exclude cervical spine injuries in obtunded or intubated patients: meta-analysis of 14,327 patients with blunt trauma. J Neurosurg. 2011;115:541–9.CrossRefGoogle Scholar
  13. 13.
    Raza M, Elkhodair S, Zaheer A, Yousaf S. Safe cervical spine clearance in adult obtunded blunt trauma patients on the basis of a normal multidetector CT scan--a meta-analysis and cohort study. Injury. 2013;44:1589–95.CrossRefGoogle Scholar
  14. 14.
    Badhiwala JH, Lai CK, Alhazzani W, Farrokhyar F, Nassiri F, Meade M, et al. Cervical spine clearance in obtunded patients after blunt traumatic injury: a systematic review. Ann Intern Med. 2015;162:429–37.CrossRefGoogle Scholar
  15. 15.
    Khanna P, Chau C, Dublin A, Kim K, Wisner D. The value of cervical magnetic resonance imaging in the evaluation of the obtunded or comatose patient with cervical trauma, no other abnormal neurological findings, and a normal cervical computed tomography. J Trauma Acute Care Surg. 2012;72:699–702.CrossRefGoogle Scholar
  16. 16.
    Steigelman M, Lopez P, Dent D, Myers J, Corneille M, Stewart R, et al. Screening cervical spine MRI after normal cervical spine CT scans in patients in whom cervical spine injury cannot be excluded by physical examination. Am J Surg. 2008;196:857–62. discussion 862–853.CrossRefGoogle Scholar
  17. 17.
    McCracken B, Klineberg E, Pickard B, Wisner DH. Flexion and extension radiographic evaluation for the clearance of potential cervical spine injures in trauma patients. Eur Spine J. 2013;22:1467–73.CrossRefGoogle Scholar
  18. 18.
    Stassen NA, Williams VA, Gestring ML, Cheng JD, Bankey PE. Magnetic resonance imaging in combination with helical computed tomography provides a safe and efficient method of cervical spine clearance in the obtunded trauma patient. J Trauma. 2006;60:171–7.CrossRefGoogle Scholar
  19. 19.
    •• Inaba K, Byerly S, Bush LD, Martin MJ, Martin DT, Peck KA, et al. Cervical spinal clearance: A prospective Western Trauma Association Multi-institutional Trial. J Trauma Acute Care Surg. 2016;81:1122–30 Large multi-institutional prospective study demonstrating that the risk of missing a clinically significant unstable cervical spine injury with a negative high-qulaity CT scan interperted by a trained neuro-radiologist, is extremely low. CrossRefGoogle Scholar
  20. 20.
    •• Duane TM, Young AJ, Vanguri P, Wolfe LG, Katzen J, Han J, et al. Defining the cervical spine clearance algorithm: a single-institution prospective study of more than 9,000 patients. J Trauma Acute Care Surg. 2016;81:541–7 Large single institutional study with a proposed algorithm for cervical spine evaluation developed through multi-stage logistic regression analysis. CrossRefGoogle Scholar
  21. 21.
    Patel MB, Humble SS, Cullinane DC, Day MA, Jawa RS, Devin CJ, et al. Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the eastern Association for the Surgery of trauma. J Trauma Acute Care Surg. 2015;78:430–41.CrossRefGoogle Scholar
  22. 22.
    Bush L, Brookshire R, Roche B, Johnson A, Cole F, Karmy-Jones R, et al. Evaluation of cervical spine clearance by computed tomographic scan alone in intoxicated patients with blunt trauma. JAMA Surg. 2016;151:807–13.CrossRefGoogle Scholar
  23. 23.
    • Martin MJ, Bush LD, Inaba K, Byerly S, Schreiber M, Peck KA, et al. Cervical spine evaluation and clearance in the intoxicated patient: A prospective Western Trauma Association Multi-Institutional Trial and Survey. J Trauma Acute Care Surg. 2017;83:1032–40 Large, prospective multi-institutional study showing limited utility of MRI after a negative CT in the intoxicated patient. CrossRefGoogle Scholar
  24. 24.
    Malhotra A, Durand D, Wu X, Geng B, Abbed K, Nunez DB, et al. Utility of MRI for cervical spine clearance in blunt trauma patients after a negative CT. Eur Radiol. 2018;28:2823–9.CrossRefGoogle Scholar
  25. 25.
    Stelfox HT, Velmahos GC, Gettings E, Bigatello LM, Schmidt U. Computed tomography for early and safe discontinuation of cervical spine immobilization in obtunded multiply injured patients. J Trauma. 2007;63:630–6.CrossRefGoogle Scholar
  26. 26.
    Dunham CM, Brocker BP, Collier BD, Gemmel DJ. Risks associated with magnetic resonance imaging and cervical collar in comatose, blunt trauma patients with negative comprehensive cervical spine computed tomography and no apparent spinal deficit. Crit Care. 2008;12:R89.CrossRefGoogle Scholar
  27. 27.
    Goradia D, Linnau KF, Cohen WA, Mirza S, Hallam DK, Blackmore CC. Correlation of MR imaging findings with intraoperative findings after cervical spine trauma. AJNR Am J Neuroradiol. 2007;28:209–15.PubMedGoogle Scholar
  28. 28.
    Albrecht RM, Malik S, Kingsley DD, Hart B. Severity of cervical spine ligamentous injury correlates with mechanism of injury, not with severity of blunt head trauma. Am Surg. 2003;69:261–5. discussion 265.PubMedGoogle Scholar
  29. 29.
    D'Alise MD, Benzel EC, Hart BL. Magnetic resonance imaging evaluation of the cervical spine in the comatose or obtunded trauma patient. J Neurosurg. 1999;91:54–9.PubMedGoogle Scholar
  30. 30.
    Wu X, Malhotra A, Geng B, Kalra VB, Abbed K, Forman HP, et al. Cost-effectiveness of magnetic resonance imaging in cervical clearance of obtunded blunt trauma after a Normal computed tomographic finding. JAMA Surg. 2018;153:625–32.CrossRefGoogle Scholar
  31. 31.
    Wu X, Malhotra A, Geng B, Liu R, Abbed K, Forman HP, et al. Cost-effectiveness of magnetic resonance imaging in cervical spine clearance of neurologically intact patients with blunt trauma. Ann Emerg Med. 2018;71:64–73.CrossRefGoogle Scholar
  32. 32.
    Chaput CD, Walgama J, Torres E, Dominguez D, Hanson J, Song J, et al. Defining and detecting missed ligamentous injuries of the occipitocervical complex. Spine (Phila Pa 1976). 2011;36:709–14.CrossRefGoogle Scholar
  33. 33.
    Riascos R, Bonfante E, Cotes C, Guirguis M, Hakimelahi R, West C. Imaging of Atlanto-occipital and atlantoaxial traumatic injuries: what the radiologist needs to know. Radiographics. 2015;35:2121–34.CrossRefGoogle Scholar
  34. 34.
    Vaccaro AR, Hulbert RJ, Patel AA, Fisher C, Dvorak M, Lehman RA Jr, et al. The subaxial cervical spine injury classification system: a novel approach to recognize the importance of morphology, neurology, and integrity of the disco-ligamentous complex. Spine (Phila Pa 1976). 2007;32:2365–74.CrossRefGoogle Scholar
  35. 35.
    Mascarenhas D, Dreizin D, Bodanapally UK, Stein DM. Parsing the utility of CT and MRI in the subaxial cervical spine injury classification (SLIC) system: is CT SLIC enough? AJR Am J Roentgenol. 2016;206:1292–7.CrossRefGoogle Scholar
  36. 36.
    Lin JL, Samuel S, Gray R, Ruff S, Vasili C, Cree A, et al. Occult subaxial cervical disco-ligamentous injuries in computer tomography negative trauma patients. Eur Spine J. 2017;26:1277–83.CrossRefGoogle Scholar
  37. 37.
    Lensing FD, Bisson EF, Wiggins RH 3rd, Shah LM. Reliability of the STIR sequence for acute type II odontoid fractures. AJNR Am J Neuroradiol. 2014;35:1642–6.CrossRefGoogle Scholar
  38. 38.
    Chang YM, Kim G, Peri N, Papavassiliou E, Rojas R, Bhadelia RA. Diagnostic utility of increased STIR signal in the posterior Atlanto-occipital and atlantoaxial membrane complex on MRI in acute C1-C2 fracture. AJNR Am J Neuroradiol. 2017;38:1820–5.CrossRefGoogle Scholar
  39. 39.
    Flanders AE, Spettell CM, Tartaglino LM, Friedman DP, Herbison GJ. Forecasting motor recovery after cervical spinal cord injury: value of MR imaging. Radiology. 1996;201:649–55.CrossRefGoogle Scholar
  40. 40.
    Martinez-Perez R, Paredes I, Cepeda S, Ramos A, Castano-Leon AM, Garcia-Fuentes C, et al. Spinal cord injury after blunt cervical spine trauma: correlation of soft-tissue damage and extension of lesion. AJNR Am J Neuroradiol. 2014;35:1029–34.CrossRefGoogle Scholar
  41. 41.
    Miyanji F, Furlan JC, Aarabi B, Arnold PM, Fehlings MG. Acute cervical traumatic spinal cord injury: MR imaging findings correlated with neurologic outcome--prospective study with 100 consecutive patients. Radiology. 2007;243:820–7.CrossRefGoogle Scholar
  42. 42.
    Zohrabian VM, Parker L, Harrop JS, Vaccaro AR, Marino RJ, Flanders AE. Can anatomic level of injury on MRI predict neurological level in acute cervical spinal cord injury? Br J Neurosurg. 2016;30:204–10.PubMedGoogle Scholar
  43. 43.
    Martinez-Perez R, Cepeda S, Paredes I, Alen JF, Lagares A. MRI prognostication factors in the setting of cervical spinal cord injury secondary to trauma. World Neurosurg. 2017;101:623–32.CrossRefGoogle Scholar
  44. 44.
    Leypold BG, Flanders AE, Burns AS. The early evolution of spinal cord lesions on MR imaging following traumatic spinal cord injury. AJNR Am J Neuroradiol. 2008;29:1012–6.CrossRefGoogle Scholar
  45. 45.
    Shah LM, Flanders AE. Update on new imaging techniques for trauma. Neurosurg Clin N Am. 2017;28:1–21.CrossRefGoogle Scholar
  46. 46.
    Desouza RM, Crocker MJ, Haliasos N, Rennie A, Saxena A. Blunt traumatic vertebral artery injury: a clinical review. Eur Spine J. 2011;20:1405–16.CrossRefGoogle Scholar
  47. 47.
    • Burlew CC, Sumislawski JJ, Behnfield CD, McNutt MK, McCarthy J, Sharpe JP, et al. Time to stroke: a Western trauma association multicenter study of blunt cerebrovascular injuries. J Trauma Acute Care Surg. 2018;85:858–66 Multi-institutional study showing high incidence of stroke with vascular injury and importance of early detection and treatment. CrossRefGoogle Scholar
  48. 48.
    Malhotra AK, Camacho M, Ivatury RR, Davis IC, Komorowski DJ, Leung DA, et al. Computed tomographic angiography for the diagnosis of blunt carotid/vertebral artery injury: a note of caution. Ann Surg. 2007;246:632–42. discussion 642–633.CrossRefGoogle Scholar
  49. 49.
    Paulus EM, Fabian TC, Savage SA, Zarzaur BL, Botta V, Dutton W, et al. Blunt cerebrovascular injury screening with 64-channel multidetector computed tomography: more slices finally cut it. J Trauma Acute Care Surg. 2014;76:279–83. discussion 284–275.CrossRefGoogle Scholar
  50. 50.
    Malhotra A, Wu X, Kalra VB, Schindler J, Matouk CC, Forman HP. Evaluation for blunt cerebrovascular injury: review of the literature and a cost-effectiveness analysis. AJNR Am J Neuroradiol. 2016;37:330–5.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Radiology and Biomedical ImagingYale University School of MedicineNew HavenUSA
  2. 2.Division of Acute Care Surgery, Department of Surgery, Larner College of MedicineLevel I Trauma Center, UVM Medical CenterBurlingtonUSA

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