Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.
Injury. 2024 Mar;55(3):111308. doi: 10.1016/j.injury.2023.111308. Epub 2023 Dec 31.
Cervical spine injuries (CSI) are often challenging to diagnose in obtunded adult patients with blunt trauma and the optimal imaging modality remains uncertain. This study systematically synthesized the last decade of evidence to determine the type of imaging required to clear the c-spine in obtunded patients with blunt trauma.
A systematic review with meta-analysis was conducted and reported using PRISMA 2020 guidelines. The protocol was registered on June 22, 2022 (PROSPERO CRD42022341386). MEDLINE (Ovid), EMBASE, and Cochrane Library were searched for studies published between January 1, 2012, and October 17, 2023. Studies comparing CT alone to CT combined with MRI for c-spine clearance were included. Two independent reviewers screened articles for eligibility in duplicate. Meta-analysis was conducted using a random-effect model. Risk of bias and quality assessment were performed using the ROBINS-I and QUADAS-2. The certainty of evidence was assessed using the GRADE methodology.
744 obtunded trauma patients from six included studies were included. Among the 584 that had a negative CT scan, the pooled missed rate of clinically significant CSI using CT scans alone was 6 % (95 % CI: 0.02 to 0.17), and the pooled missed rate of CSI requiring treatment was 7 % (95 % CI: 0.02 to 0.18). High heterogeneity was observed among included studies (I² > 84 %). The overall risk of bias was moderate, and the quality of evidence was low due to the retrospective nature of the included studies and high heterogeneity.
Limited evidence published in the last decade found that CT scans alone may not be sufficient for detecting clinically significant CSI and injuries requiring treatment in obtunded adult patients with blunt trauma.
Clinicians should be aware of the limitations of CT scans and consider using MRI when appropriate. Future research should focus on prospective studies with standardized outcome measures and uniform reporting.
颈椎损伤（CSI）在钝器伤意识障碍的成年患者中常常难以诊断，且最佳影像学检查方式仍不确定。本研究系统综合了过去十年的证据，以确定在钝器伤意识障碍患者中清除颈椎所需的影像学检查类型。
进行了系统评价和荟萃分析，并按照 PRISMA 2020 指南进行报告。该方案于 2022 年 6 月 22 日注册（PROSPERO CRD42022341386）。检索了 2012 年 1 月 1 日至 2023 年 10 月 17 日期间发表的 MEDLINE（Ovid）、EMBASE 和 Cochrane 图书馆中的研究。纳入比较单独 CT 与 CT 联合 MRI 用于颈椎清除的研究。两名独立的审查员重复筛选文章的纳入资格。使用随机效应模型进行荟萃分析。使用 ROBINS-I 和 QUADAS-2 进行风险偏倚和质量评估。使用 GRADE 方法评估证据的确定性。
纳入的 6 项研究共纳入了 744 例意识障碍的创伤患者。在 584 例 CT 扫描阴性的患者中，单独使用 CT 扫描时，临床显著 CSI 的漏诊率为 6%（95%CI：0.02-0.17），需要治疗的 CSI 的漏诊率为 7%（95%CI：0.02-0.18）。纳入的研究存在高度异质性（I²＞84%）。总体风险偏倚为中度，证据质量低，原因是纳入的研究为回顾性研究，且存在高度异质性。
过去十年发表的有限证据表明，单独 CT 扫描可能不足以检测钝器伤意识障碍的成年患者中的临床显著 CSI 和需要治疗的损伤。
临床医生应认识到 CT 扫描的局限性，并在适当情况下考虑使用 MRI。未来的研究应侧重于前瞻性研究，采用标准化的结局测量和统一的报告。
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