Purpose: The Eastern Association for the Surgery of Trauma (EAST) has clearly stated clinical practice management guidelines in the evaluation of the traumatic cervical spine. However, no clear practice guidelines are in place for the obtunded patient. Concurrent and conflicting opinions range from long-term collar use, flexion/extension views under fluoroscopy, and full cervical spine MRI. To date, no consensus has been reached. The purpose of this study is to attempt to answer the question: If the entire cervical spine of an obtunded patient is normal by helical CT, how often, does cervical spine MRI show a clinically relevant finding?
Methods and Materials: From January 1999 - January 2003, 300 obtunded patients admitted to the R. Adams Cowley Shock Trauma Center had full cervical spine MRI studies for the evaluation of soft tissue injuries after having normal complete cervical spine CT scans. Axial T2 and gradient echo as well as sagittal inversion recovery, proton density, T1- and T2-weighted sequences were performed. In all patients, the cervical spine MRI was performed because a cervical spine soft tissue injury could not be excluded by physical examination.
Results: 300 patients aged 14-92 (mean 41.2) years were included in the study. 140 (46.7%) were involved in motor vehicle collisions, 52 (17.3%) in a fall, 36 (12.0%) in an assault, and finally, 23 (7.6%) were pedestrians struck by a vehicle. 295 (98.3%) of the 300 patients had cervical spine MRIs that showed no soft tissue injury. 5 did show soft tissue injuries; however, all of these patients had stable one-column injuries. No patient had a 2 or 3 column injury, unstable injury, or injury requiring surgical fixation.
Conclusion: Multidetector-row CT imaging of the cervical spine may in fact be sufficient in the obtunded patient if normal cervical spine alignment and anatomy is seen. While some soft tissue injuries may be missed with a normal total CT of the cervical spine, an unstable injury is deemed very unlikely. Although a multi-center, prospective study should be performed, a new imaging guideline algorithm in the obtunded patient should be considered that does not require MRI if a technically adequate full cervical spine CT is normal.