Consultant Emergency Medicine, Frimley Park Hospital, Frimley, UK.
Injury. 2013 Nov;44(11):1589-95. doi: 10.1016/j.injury.2013.06.005. Epub 2013 Jul 12.
A true gold standard to rule out a significant cervical spine injury in subset of blunt trauma patients with altered sensorium is still to be agreed upon. The objective of this study is to determine whether in obtunded adult patients with blunt trauma, a clinically significant injury to the cervical spine be ruled out on the basis of a normal multidetector cervical spine computed tomography.
Comprehensive database search was conducted to include all the prospective and retrospective studies on blunt trauma patients with altered sensorium undergoing cervical spine multidetector CT scan as core imaging modality to "clear" the cervical spine. The studies used two main gold standards, magnetic resonance imaging of the cervical spine and/or prolonged clinical follow-up. The data was extracted to report true positive, true negatives, false positives and false negatives. Meta-analysis of sensitivity, specificity, negative and positive predictive values was performed using Meta Analyst Beta 3.13 software. We also performed a retrospective investigation comparing a robust clinical follow-up and/or cervical spine MR findings in 53 obtunded blunt trauma patients, who previously had undergone a normal multidetector CT scan of the cervical spine reported by a radiologist.
A total of 10 studies involving 1850 obtunded blunt trauma patients with initial cervical spine CT scan reported as normal were included in the final meta-analysis. The cumulative negative predictive value and specificity of cervical spine CT of the ten studies was 99.7% (99.4-99.9%, 95% confidence interval). The positive predictive value and sensitivity was 93.7% (84.0-97.7%, 95% confidence interval). In the retrospective review of our obtunded blunt trauma patients, none was later diagnosed to have significant cervical spine injury that required a change in clinical management.
In a blunt trauma patient with altered sensorium, a normal cervical spine CT scan is conclusive to safely rule out a clinically significant cervical spine injury. The results of this meta-analysis strongly support the removal of cervical precautions in obtunded blunt trauma patient after normal cervical spine computed tomography. Any further imaging like magnetic resonance imaging of the cervical spine should be performed on case-to-case basis.
在意识改变的钝器创伤患者亚组中，排除显著颈椎损伤的真正金标准仍有待达成共识。本研究的目的是确定在意识改变的钝器创伤成年患者中，是否可以基于正常的多层颈椎 CT 扫描排除颈椎的临床显著损伤。
进行全面的数据库检索，纳入所有前瞻性和回顾性研究，这些研究纳入了意识改变的钝器创伤患者，将多层颈椎 CT 扫描作为核心成像方式来“清除”颈椎。这些研究使用了两种主要的金标准，即颈椎磁共振成像和/或延长的临床随访。提取数据以报告真阳性、真阴性、假阳性和假阴性。使用 Meta Analyst Beta 3.13 软件对敏感性、特异性、阴性和阳性预测值进行荟萃分析。我们还进行了一项回顾性研究，比较了在 53 名意识改变的钝器创伤患者中的稳健临床随访和/或颈椎磁共振结果，这些患者之前曾接受过放射科医生报告的正常多层颈椎 CT 扫描。
共有 10 项研究纳入了 1850 名初始颈椎 CT 扫描正常的意识改变的钝器创伤患者，最终的荟萃分析纳入了这 10 项研究。10 项研究的颈椎 CT 累积阴性预测值和特异性为 99.7%（99.4-99.9%，95%置信区间）。阳性预测值和敏感性为 93.7%（84.0-97.7%，95%置信区间）。在我们对意识改变的钝器创伤患者的回顾性研究中，没有患者后来被诊断为需要改变临床管理的显著颈椎损伤。
在意识改变的钝器创伤患者中，正常的颈椎 CT 扫描足以确定是否存在临床显著的颈椎损伤。荟萃分析的结果强烈支持在正常颈椎 CT 后，移除意识改变的钝器创伤患者的颈椎防护措施。任何进一步的成像，如颈椎磁共振成像，应根据具体情况进行。
