Como John J, Leukhardt William H, Anderson James S, Wilczewski Patricia A, Samia Hoda, Claridge Jeffrey A
Division of Trauma, Critical Care, and Burns, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio 44109, USA.
J Trauma. 2011 Feb;70(2):345-9; discussion 349-51. doi: 10.1097/TA.0b013e3182095b3c.
Cervical spine (CS) clearance in obtunded blunt trauma patients (OBTPs) remains controversial. When computed tomography (CT) of the CS is negative for injury, debate continues over the role of magnetic resonance imaging (MRI). Use of MRI in OBTPs is costly, time-consuming, and potentially dangerous. Our study evaluated the safety of a protocol to discontinue the cervical collar in OBTPs based on CT scan alone.
A prospective study was performed from October 2006 to September 2008 at a regional Level I trauma center on OBTPs with gross movement of all extremities. After a CT of the CS was read as negative for injury, the CS was cleared and the collar was removed. Patients were then followed prospectively for related complications.
One hundred ninety-seven patients had their collars removed and CS cleared at a mean of 3.3 days. There were 144 males (73%), and the average age was 47.1 years. Sixty-two percent of patients were reexamined by a physician when no longer obtunded and found to have no CS signs or symptoms. Five patients (2.5%), when no longer obtunded, had persistent pain for which MRI CS was negative for injury. Coroner reports and autopsies were reviewed for missed spinal cord injuries in the 13% who died before reexamination. One of these patients had an autopsy report of an isolated CS ligamentous injury, deemed to be stable by our attending neurosurgeon. We followed up an additional 12% by phone or chart review, with no report of new onset neurologic deficit. The remaining 11% were lost to follow-up, but no patient contacted our hospital to report deterioration in function. One patient (0.5%) developed a minor CS decubitus ulceration.
Removal of CS precautions in OBTPs with gross movement of all extremities is safe and efficacious if CT CS is negative for injury. Supplemental MRI CS is not needed in this patient population.
钝性创伤致昏迷患者（OBTPs）的颈椎（CS）评估仍存在争议。当CS的计算机断层扫描（CT）未发现损伤时，关于磁共振成像（MRI）的作用仍存在争论。在OBTPs中使用MRI成本高、耗时且有潜在风险。我们的研究评估了仅基于CT扫描就停用OBTPs患者颈托方案的安全性。
2006年10月至2008年9月，在一家地区一级创伤中心对所有四肢能自主活动的OBTPs进行了一项前瞻性研究。在CS的CT检查结果显示无损伤后，CS被评估为正常且颈托被移除。然后对患者进行前瞻性随访以观察相关并发症。
197例患者的颈托被移除且CS被评估为正常，平均时间为3.3天。其中男性144例（73%），平均年龄47.1岁。62%的患者在不再昏迷时由医生进行了复查，未发现CS相关体征或症状。5例患者（2.5%）在不再昏迷时仍有持续性疼痛，其CS的MRI检查未发现损伤。对13%在复查前死亡患者的验尸官报告和尸检进行了回顾，以查找漏诊的脊髓损伤。其中1例患者的尸检报告显示存在孤立的CS韧带损伤，经我们的主治神经外科医生判断为稳定。我们通过电话或病历审查对另外12%的患者进行了随访，未报告有新发神经功能缺损。其余11%的患者失访，但没有患者联系我院报告功能恶化。1例患者（0.5%）出现了轻微的CS褥疮溃疡。
对于所有四肢能自主活动的OBTPs，如果CS的CT检查未发现损伤，移除CS防护措施是安全有效的。该患者群体无需进行补充性CS的MRI检查。
