Downloaded from http://journals.lww.com/jaaos by BhDMf5ePHKbH4TTImqenVBeBkEmDgYgARCSrO1DUnzGi9QjoukYv+RKdqk+yL/v0X0Kqy+pjGEU= on 12/09/2019 Review Article Evaluating the Cervical Spine in the Blunt Trauma Patient Abstract Following a blunt trauma, the goal of the cervical spine evaluation is to identify any injuries that might require active management: either through continued use of a collar or surgical stabilization. This is achieved through a step-wise approach that considers the nature of the patient’s trauma, presenting complaints, distracting injuries and capacity to cooperate with the examination. In the last 15 to 20 years, technological advances in radiographic imaging have improved clinicians’ abilities to certify the cervical spine as free of injury following blunt trauma. Within the last decade, the use of CT has supplanted plain radiograph imaging as the standard screening modality. Although MRI is more sensitive than CT in identifying occult cervical injury, particularly ligamentous or soft-tissue trauma, the standard addition of MRI to CT evaluation alone does not significantly increase the detection of clinically important cervical injuries. T he evaluation of the cervical spine in the adult trauma patient has been a priority in the standard trauma assessment since the incep- tion of the advanced trauma life support (ATLS) protocol, more than 30 years ago. 1 Current estimates maintain that more than 10 million adults present to medical centers annually for the evaluation of in- juries sustained as a result of trauma, with 3% to 6% anticipated to have an injury involving the cervical spine. 2 Although the incidence of cervical spine trauma is relatively low, permanent injuries that result from spinal cord trauma or other neurologic compromise can be dev- astating events with long-term im- plications for survival, physical function, future income and health- care costs. 3–8 The risk of neurologic injury increases substantially in the setting of undetected cervical trauma 8 and this rationale underlies the ATLS tenet that all patients should be assumed to have sustained a cervical spine injury until proven otherwise. 1,3,7 Certification of the cervical spine as free of significant injury, generally referred to as “cervical spine clear- ance,” is relatively straight forward in the patient who is awake and alert and who can tolerate and actively participate in a complete spinal and neurological assessment. 3,9,10 The evaluation process is more complex in individuals who are temporar- ily unevaluable due to other life- threatening or distracting injuries or those who cannot participate in an examination due to intoxication or depressed Glasgow Coma Scale (GCS) score. 7 This latter group is often referred to as obtunded, although the term as used in the medical litera- ture has been maintained to be overly broad and imprecise, encompassing as it does patients with a mental status ranging from mildly intoxicated to those in a frank coma. 11 A step-wise approach to the evalu- ation and clearance of the cervical Andrew J. Schoenfeld, MD, MSc Aaron W. Beck, MD Mitchel B. Harris, MD Paul A. Anderson, MD From the Department of Orthopaedic Surgery (Dr. Schoenfeld and Dr. Beck), Brigham and Women’s Hospital, Harvard Medical School, the Department of Orthopaedic Surgery (Dr. Harris), Massachusetts General Hospital, Harvard Medical School, Boston, MA, and the Department of Orthopedic Surgery and Rehabilitation, University of Wisconsin, Madison, WI (Dr. Anderson). Dr. Schoenfeld receives funding outside this work from the National Institutes of Health-NIAMS, Department of Defense, OREF and Centers for Medicare and Medicaid Services. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Beck, Dr. Harris, and Dr. Anderson. J Am Acad Orthop Surg 2019;27: 633-641 DOI: 10.5435/JAAOS-D-18-00695 Copyright 2019 by the American Academy of Orthopaedic Surgeons. September 1, 2019, Vol 27, No 17 633 Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.