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Cervical spine clearance protocols in Level I, II, and III trauma centers in California
Murat Pekmezci1, Alexander A Theologis1, Robert Dionisio1
1Department of Orthopaedic surgery, Orthopaedic Trauma Institute, University of California-San Francisco (UCSF)/San Francisco General Hospital (SFGH), 2550 23rd St, Bldg 9, 2nd Floor, San Francisco, CA 94110, USA.
Background Context:
Cervical spine clearance protocols were developed to standardize the clearance of the cervical spine after blunt trauma and prevent secondary neurologic injuries. The degree of incorporation of evidence-based guidelines into protocols at trauma centers in California is unknown.
Purpose:
To evaluate the cervical spine clearance protocols in all trauma centers of California.
Study Design:
An observational cross-sectional study.
Patient Sample:
Included from Level I, II, III trauma centers in California.
Outcome Measures:
The self-reported outcomes of each trauma center's cervical spine clearance protocols were assessed.
Methods:
Level I (n=15), II (n=30), and III (n=11) trauma centers in California were contacted. Each available protocol was reviewed for four scenarios: clearing the asymptomatic patient, the initial imaging modality used in patients not amenable to clinical clearance, and the management strategies for patients with persistent neck pain with a negative computed tomography (CT) scan and those who are obtunded. Results were compared with the 2009 Eastern Association for the Surgery of Trauma (EAST) cervical spine clearance guidelines.
Results:
The response rate was 96%. Sixty-three percent of California's trauma centers (Level I, 93%; Level II, 60%; Level III, 27%) had written cervical spine clearance protocols. For asymptomatic patients, 83% of Level I and 61% of Level II centers used National Emergency X-Radiography Utilization Study criteria with/without painless range of motion. For those requiring imaging, 67% of Level I and 56% of Level II centers stated a CT scan should be the first line of imaging. For obtunded patients and patients with persistent neck pain and a negative CT scan, more than 90% of Level I and more than 70% of Level II trauma centers incorporated the 2009 EAST recommendations. No institution recommended passive flexion-extension radiographs for the obtunded patient.
Conclusions:
Written cervical spine clearance protocols exist in 63% of California's trauma centers and only 51% of the centers have protocols that follow current evidence-based guidelines. Standardization and utilization of these protocols should be encouraged to prevent missed injuries and secondary neurologic injuries.
