MRI Is Not Needed for Cervical Spine Clearance in Obtunded Blunt Trauma Patients

This is important because we are often asked to intubate these patients.

Authors: Badhiwala JH et al., Ann Intern Med 2015 Mar 17; 162:429

A systematic review found no significant missed injuries in obtunded blunt trauma patients who had normal CT imaging of their cervical spines.

Given the significant morbidity and mortality associated with missed traumatic cervical spine injuries, patients in whom a reliable clinical exam is unobtainable are often evaluated with magnetic resonance imaging (MRI) following a normal computed tomography (CT) scan. A number of small studies have demonstrated that this practice does not affect outcomes (NEJM JW Emerg Med Dec 2007 and J Trauma 2007; 63:538; NEJM JW Emerg Med Apr 2012 and J Trauma 2012; 72:699; NEJM JW Emerg Med Jan 2012 and Ann Emerg Med2011; 58:521); however, none has led to a change in this practice. These authors performed a systematic review to determine the utility of MRI after normal CT results in blunt trauma patients who were obtunded (Glasgow Coma Scale score ≤14, unreliable clinical exam, or intubated).

The analysis included seven studies deemed high quality (prospective, low risk of bias, CT scans interpreted by attending-level radiologists, CT scanners with narrow [1 to 3 mm] slice width and multiplanar reconstruction). The studies included a total of 1686 patients. Among patients with normal CT results, there were no injuries identified by MRI or clinical follow-up that were of any clinical consequence (unstable, required operative intervention, or needed collar immobilization).

Comment
Obtunded blunt trauma patients with normal narrow-slice cervical spine CTs interpreted by attending radiologists can, and should, be taken out of their cervical collars without MRI.