Cervical spine immobilization following blunt trauma: a systematic review of recent literature and proposed treatment algorithm.

BACKGROUND: Management of the cervical spine following blunt trauma is commonplace. In 2013, the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) published practice guidelines drawn from evidence dating to 2011. Since then, further publications have emerged that are reviewed, and a simple management algorithm produced to assist practitioners in Australian trauma centres. These publications attempt to shed light on two controversial scenarios, those being the management of symptomatic patients with negative computed tomography (CT) and management of the obtunded patient.

METHODS: The search strategy mirrored that of the AANS/CNS guidelines. A search of the National Library of Medicine (PubMed) database for manuscripts published between January 2011 and October 2014 was conducted. One reviewer extracted data from studies assessing the performance of various imaging modalities in identifying traumatic cervical spine injuries. In clinical scenarios where little evidence has emerged since the AANS/CNS guidelines, key manuscripts published prior to 2011 were identified from bibliographies.

RESULTS: Awake, asymptomatic patients may be 'cleared' without further imaging. Awake, symptomatic patients without pathology on CT and without neurological deficit can safely be 'cleared' without magnetic resonance imaging. There is no longer a role for flexion-extension films. In the obtunded patient, findings remain conflicting.

CONCLUSION: Several of these findings represent a departure from previous practices, including clearance of patients with non-neurological symptoms on the basis of CT and the exclusion of flexion-extension film in detecting injury. Management of the obtunded patient remains controversial.