prevalence of cervical spinal injury in trauma · social, and economic...

Neurosurg. Focus / Volume 25 / November 2008

Neurosurg Focus 25 (5):E10, 2008

1

Quadriplegia due to spinal cord injury is a dev-astating consequence of trauma to the cervical spine, involving numerous functional, psycho-

social, and economic ramifications.7,12,13,24,25,27–29,45,

49,61 Identification of unstable CSI is therefore an essential aspect of the trauma evaluation in preventing subsequent neurological damage.6,22,71,72,75,76 This task is especially difficult in patients who are not clinically evaluable (un-evaluable group) because of intoxication or concomitant head injury, and has led to the use of advanced imaging techniques such as CT and MR imaging for radiologi-cal clearance.1,2,15,20,58,83,90,91 Continued advances in imag-ing quality and sensitivity now raise questions about the practice of clearing even alert, low-risk patients by clini-cal criteria alone,30 and have precluded the establishment of any consensus regarding the appropriate indications for the use of imaging studies.58,65,67,85,90

Although a lower threshold for the use of advanced imaging would hypothetically result in the detection and possible prevention of a greater number of CSIs, these benefits must be weighed against the associated risks and considerable costs of performing such studies and the additional treatments initiated due to false-positive results.18,19,41,77 Indeed, complications have been reported

in 6–71% of critically ill patients during and after trans-port.94 Accurate knowledge of the prevalence of CSI in trauma patients is therefore essential for assessing the need for immobilization and/or further imaging. Scat-tered studies of CSI in clinical series composed of all trauma patients report CSI prevalences ranging from 1 to 14%.59,87 However, unevaluable patients require a higher index of suspicion than the general trauma popu-lation,5,46,51,64,80,96 with one patient series estimating that a GCS score ≤ 8 incurs an almost 6-fold increase in the risk of CSI.50 Numerous patient series have examined the sensitivities of various imaging modalities in the detec-tion of CSI, and as such represent a large volume of data from which to calculate overall prevalence. However, considerable variation exists in rates of radiographic evi-dence of CSI, with 1 study reporting CT or MR imaging findings in 40% of obtunded patients.90 By systematically pooling data from relevant clinical series, more general-izable estimates of CSI prevalence in all trauma patients, alert patients, and unevaluable patients with trauma can be determined, along with the proportion of patients whose unstable injuries confer a risk of quadriplegia.

MethodsWe performed English-language searches of Med-

line and PubMed for articles published between 1985

Prevalence of cervical spinal injury in trauma

Andrew H. Milby, b.S.,1 CASey H. HAlpern, M.d.,1 wenSHeng guo, pH.d.,2 And SHerMAn C. Stein, M.d.11Department of Neurosurgery, Hospital of the University of Pennsylvania; and 2Center for Clinical Epidemi-ology and Biostatistics, University of Pennsylvania, School of Medicine, Philadelphia, Pennsylvania

Object. Diagnosis of cervical spinal injury (CSI) is an essential aspect of the trauma evaluation. This task is especially difficult in patients who are not clinically able to be evaluated (unevaluable) because of distracting pain-ful injuries, intoxication, or concomitant head injury. For this population, the appropriate use of advanced imaging techniques for cervical spinal clearance remains undetermined. This study was undertaken to estimate the prevalence of unstable CSI, particularly among patients in whom clinical evaluation is impossible or unreliable.

Methods. Estimates of the prevalence of CSI in populations consisting of all trauma patients, alert patients only, and clinically unevaluable patients only were determined by variance-weighted pooling of data from 65 publications (281,864 patients) that met criteria for review.

Results. The overall prevalence of CSI among all trauma patients was 3.7%. The prevalence of CSI in alert pa-tients was 2.8%, whereas unevaluable patients were at increased risk of CSI with a prevalence of 7.7% (p = 0.007). Overall, 41.9% of all CSI cases were considered to exhibit instability.

Conclusions. Trauma patients who are clinically unevaluable have a higher prevalence of CSI than alert patients. Knowledge of the prevalence and risk of such injuries may help establish an evidence-based approach to the detection and management of clinically occult CSI. (DOI: 10.3171/FOC.2008.25.11.E10)

Key wordS • cervical spine injury • prevalence • trauma

1

Abbreviations used in this paper: CSI = cervical spine injury; GCS = Glasgow Coma Scale.

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A. H. Milby et al.

2 Neurosurg. Focus / Volume 25 / November 2008

Tabl

e 1:

Pre

vale

nce

of C

SI in

all

trau

ma

patie

nts

Auth

or &

Yea

rSe

tting

Cas

e Ac

crua

l Met

hod

Patie

nt P

opul

atio

nN

o. o

f Pa

tient

sIn

jury

Inci

denc

e

Bani

t et a

l., 2

000

sing

le U

S Le

vel I

trau

ma

cent

erre

trosp

ectiv

e ev

alua

tion

of c

linic

al a

lgor

ithm

all t

raum

a ad

mis

sion

s44

600.

036

Bayl

ess

& R

ay, 1

989

sing

le U

S Le

vel I

trau

ma

cent

erre

trosp

ectiv

e ob

serv

atio

nal

blun

t hea

d tra

uma

adm

issi

ons

176

0.01

7Bo

rock

et a

l., 1

991

sing

le U

S Le

vel I

trau

ma

cent

erre

trosp

ectiv

e ev

alua

tion

of c

linic

al a

lgor

ithm

blun

t tra

uma

adm

issi

ons

179

0.08

4C

ox e

t al.,

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ngle

US

Leve

l I tr

aum

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pros

pect

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n of

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ical

alg

orith

mal

l tra

uma

adm

issi

ons

910.

044

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etria

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ma

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550.

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50.

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oth

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407

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3

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Leve

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lm

otor

veh

icle

cra

sh tr

aum

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s77

50.

119

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t al.,

200

121

US

univ

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ty a

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omm

unity

hos

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serv

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nal

blun

t tra

uma

adm

issi

ons

34,0

690.

024

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feld

et a

l., 1

988

four

US

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a ce

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sre

trosp

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alua

tion

of c

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nec

k tra

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adm

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886

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rk, 2

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n21

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trosp

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serv

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nal

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titra

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adm

issi

ons

6500

0.07

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t al.,

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unde

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ng C

T67

60.

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erge

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467

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rs, 1

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480

0.03

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410

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ons

2603

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arm

a et

al.,

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genc

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adm

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ons

9903

0.01

3

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ri et

al.,

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ervi

cal C

T43

40.

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045

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r et a

l., 2

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ma

regi

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ctiv

e ob

serv

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nal

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t ped

estri

ans

inju

red

by v

ehic

les

6766

0.02

6



Prevalence of cervical spine injury in trauma

3

and January 2008. The search used various combinations of the key words “spinal injuries,” “cervical vertebrae,” “instability,” “trauma,” “clearance,” “neck,” “diagnosis,” “epidemiology,” “prevalence,” and “incidence.” We re-fined the search by eliminating laboratory studies, case reports, editorials, or reviews without newly reported data, and case series with duplicated or overlapping data. These findings were supplemented by using the “Find Similar” and “Find Citing Articles” features of Medline and “Related Articles” feature of PubMed, as well as the bibliographies of selected articles. Articles were analyzed and compared with reference to the setting, study organi-zation, definitions of clinical criteria, and data collection methods. Studies restricted to children < 15 years of age were excluded. If a study reported prevalence rates from pediatric cases separately from those in an adult popula-tion, these data were also excluded from the analysis.

Studies meeting our criteria for inclusion were or-ganized into 3 categories: those composed of all trauma patients, alert patients, and unevaluable patients with trauma. Those studies reporting rates of instability upon detection of CSI were also placed into a fourth catego-ry, which overlapped in part with the previously listed categories. The “all trauma” category contained series in which patients were not further classified by clinical evaluability on presentation. These series were composed of patients with either unrestricted blunt and penetrating trauma or blunt trauma alone, whereas those composed solely of patients with penetrating trauma were excluded. Patients were deemed alert if they had reliable clinical ex-amination findings, consisting minimally of being able to respond to questions regarding neck pain and cooperate with neck movement instructions. Patients were consid-ered unevaluable if impaired consciousness, inebriation, confusion, endotracheal intubation, or distracting injuries rendered the clinical examination of the cervical spine unreliable. An unstable injury was defined as any frac-ture, dislocation, or purely ligamentous injury necessitat-ing external stabilization and/or operative fixation. Data concerning unstable injuries were pooled from all series reporting their prevalence without subclassification on the basis of clinical evaluability.

Mean prevalence values for each group were ob-tained using variance-weighted pooling. A mixed-effects logistic regression model was used, using SAS PROC NLMIXED (SAS, Inc.). Data within each study were considered a cluster and a hierarchical model was used to calculate the average prevalence rate. The binary nature of the outcome allowed the use of summary statistics as a proxy for the entire data set. The effect across studies was assumed to vary as a normal distribution. The overall prevalence rate was calculated as the population-average estimate, together with its 95% confidence intervals. Mean prevalence values for alert and unevaluable patients were compared, using a likelihood ratio test for pooled data.60 We considered differences with a probability value < 0.05 to be statistically significant.

ResultsSixty-five studies with a total of 281,864 subjects Ta

ble

2: P

reva

lenc

e of

CSI

in a

lert

trau

ma

patie

nts

Auth

or &

Yea

rSe

tting

Cas

e Ac

crua

l Met

hod

Patie

nt P

opul

atio

nN

o. o

f Pa

tient

s

Inju

ryIn

ci-

denc

e

Barb

a et

al.,

200

1si

ngle

US

Leve

l I tr

aum

a ce

nter

retro

spec

tive

eval

uatio

n of

clin

ical

alg

orith

mtra

uma

adm

issi

ons

unde

rgoi

ng c

ervi

cal C

T32

40.

046

Erso

y et

al.,

199

5si

ngle

Tur

kish

uni

vers

ity h

ospi

tal e

mer

-ge

ncy

depa

rtmen

tre

trosp

ectiv

e ob

serv

atio

nal

cons

ciou

s an

d or

ient

ed b

lunt

trau

ma

adm

issi

ons

303

0.04

3

Gon

zale

z et

al.,

199

9si

ngle

US

Leve

l I tr

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pect

ive

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rvat

iona

law

ake

and

aler

t blu

nt tr

aum

a ad

mis

sion

s21

760.

015

McN

amar

a et

al.,

198

8si

ngle

US

Leve

l II t

raum

a ce

nter

pros

pect

ive

obse

rvat

iona

lpa

tient

s w

ith n

eck

pain

follo

win

g tra

umat

ic in

jury

351

0.02

0M

cNam

ara

et a

l., 1

990

sing

le U

S Le

vel I

I tra

uma

cent

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trosp

ectiv

e ob

serv

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nal

aler

t, no

nint

oxic

ated

blu

nt tr

aum

a ad

mis

sion

s28

60.

017

Rot

h et

al.,

199

4si

ngle

US

milit

ary

med

ical

cen

ter

pros

pect

ive

coho

rtal

ert,

noni

ntox

icat

ed b

lunt

trau

ma

adm

issi

ons

286

0.01

7St

iell

et a

l., 2

001

10 C

anad

ian

traum

a ce

nter

spr

ospe

ctiv

e ev

alua

tion

of c

linic

al a

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ithm

patie

nts

with

acu

te b

lunt

trau

ma

to h

ead

or n

eck

8924

0.01

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iell

et a

l., 2

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9 C

anad

ian

terti

ary

care

hos

pita

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tion

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linic

al a

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ithm

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with

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te b

lunt

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ma

to h

ead

or n

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8283

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bel e

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rvat

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ert t

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a ad

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s35

30.

025


A. H. Milby et al.


Tabl

e 3:

Pre

vale

nce

of C

SI in

clin

ical

ly u

neva

luab

le tr

aum

a pa

tient

s*

Auth

or &

Yea

rSe

tting

Cas

e Ac

crua

l Met

hod

Patie

nt P

opul

atio

nN

o. o

f Pa

tient

sIn

jury

Inci

denc

e

Bolin

ger e

t al.,

200

4si

ngle

US

Leve

l I tr

aum

a ce

nter

pros

pect

ive

eval

uatio

n of

clin

ical

alg

orith

mpa

tient

s w

ith T

BI a

nd G

CS

scor

es <

844

600.

036

Broo

ks &

Wille

tt, 2

001

sing

le U

K tra

uma

cent

erre

trosp

ectiv

e ob

serv

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nal

unco

nsci

ous

traum

a pa

tient

s17

60.

017

Chi

u et

al.,

200

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ngle

US

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l I tr

aum

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spec

tive

obse

rvat

iona

lpa

tient

s w

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CS

scor

es <

15

on a

dmis

sion

179

0.08

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al.,

199

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ries

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s or

dis

tract

ing

inju

ries

1757

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219

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al.,

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it42

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fiths

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serv

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nal

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nsci

ous

or s

emic

onsc

ious

trau

ma

patie

nts

145

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ogan

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with

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3-1

2, o

r GC

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ore

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with

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T ab

norm

ality

860

0.02

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et a

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K tra

uma

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e ob

serv

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nal

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nts

intu

bate

d fo

r pol

ytra

uma

604

0.05

0Ki

hicz

ak e

t al.,

200

1si

ngle

US

Leve

l I tr

aum

a ce

nter

retro

spec

tive

obse

rvat

iona

lun

eval

uabl

e pa

tient

s un

derg

oing

MR

imag

ing

afte

r neg

a-tiv

e C

T66

70.

090

Pada

yach

ee e

t al.,

200

6si

ngle

UK

traum

a ce

nter

pros

pect

ive

obse

rvat

iona

lun

cons

ciou

s w

ith T

BI in

ICU

407

0.14

3Pi

att e

t al.,

200

6al

l Pen

nsyl

vani

a tra

uma

cent

ers

retro

spec

tive

obse

rvat

iona

lTB

I w/ G

CS

scor

es <

877

50.

119

Sche

narts

et a

l., 2

001

sing

le U

S Le

vel I

trau

ma

cent

erpr

ospe

ctiv

e ev

alua

tion

of c

linic

al a

lgor

ithm

alte

red

men

tal s

tatu

s af

ter b

lunt

trau

mat

ic in

jury

34,0

690.

024

Sees

et a

l., 1

998

sing

le U

S m

ilitar

y m

edic

al c

ente

rre

trosp

ectiv

e ob

serv

atio

nal

unre

spon

sive

or o

btun

ded

with

GC

S sc

ores

≤ 1

088

60.

030

Stas

sen

et a

l., 2

006

sing

le U

S Le

vel I

trau

ma

cent

erre

trosp

ectiv

e ev

alua

tion

of c

linic

al a

lgor

ithm

obtu

nded

blu

nt tr

aum

a pa

tient

s21

90.

014

Wid

der e

t al.,

200

4si

ngle

Can

adia

n Le

vel I

trau

ma

cent

erpr

ospe

ctiv

e ob

serv

atio

nal

obtu

nded

blu

nt tr

aum

a pa

tient

s65

000.

072

* IC

U =

inte

nsiv

e ca

re u

nit;

TBI =

trau

mat

ic b

rain

inju

ry.




5

Tabl

e 4:

Pre

vale

nce

of u

nsta

ble

CSI

s in

all

trau

ma

patie

nts

Auth

or &

Yea

rSe

tting

Cas

e Ac

crua

l Met

hod

Patie

nt P

opul

atio

nN

o. o

f Pa

tient

sIn

jury

Inci

denc

e

Bani

t et a

l., 2

000

sing

le U

S Le

vel I

trau

ma

cent

erre

trosp

ectiv

e ev

alua

tion

of c

linic

al

algo

rithm

all t

raum

a ad

mis

sion

s15

10.

291

Bern

e et

al.,

199

9si

ngle

US

Leve

l I tr

aum

a ce

nter

pros

pect

ive

obse

rvat

iona

lbl

unt t

raum

a w

ith in

toxi

catio

n or

par

alyt

ics

200.

400

Chi

u et

al.,

200

1si

ngle

US

Leve

l I tr

aum

a ce

nter

retro

spec

tive

obse

rvat

iona

lpa

tient

s w

ith G

CS

scor

es <

15

on a

dmis

sion

471

0.55

6D

avis

et a

l., 1

993

6 U

S tra

uma

cent

ers

retro

spec

tive

obse

rvat

iona

lal

l tra

uma

adm

issi

ons

740

0.18

1D

emet

riade

s et

al.,

200

0si

ngle

US

Leve

l I tr

aum

a ce

nter

retro

spec

tive

obse

rvat

iona

lbl

unt t

raum

a ad

mis

sion

s29

20.

219

Free

dman

et a

l., 2

005

sing

le A

ustra

lian

traum

a ce

nter

retro

spec

tive

obse

rvat

iona

lun

cons

ciou

s tra

uma

patie

nts

adm

itted

to IC

U7

0.71

4G

eck

et a

l., 2

001

sing

le U

S Le

vel I

trau

ma

cent

erre

trosp

ectiv

e ob

serv

atio

nal

patie

nts

with

hig

h-en

ergy

mec

hani

sms

of in

jury

30.

333

Ger

relts

et a

l., 1

991

sing

le U

S Le

vel I

trau

ma

cent

erre

trosp

ectiv

e ob

serv

atio

nal

blun

t tra

uma

adm

issi

ons

500.

400

Gol

dber

g et

al.,

200

121

US

univ

ersi

ty a

nd c

omm

unity

ho

spita

lsre

trosp

ectiv

e ob

serv

atio

nal

blun

t tra

uma

adm

issi

ons

818

0.70

7

Grif

fiths

et a

l., 2

002

sing

le U

S Le

vel I

trau

ma

cent

erre

trosp

ectiv

e ob

serv

atio

nal

unco

nsci

ous

or s

emic

onsc

ious

trau

ma

patie

nts

21.

000

Har

ris e

t al.,

200

0si

ngle

US

Leve

l I tr

aum

a ce

nter

pros

pect

ive

eval

uatio

n of

clin

ical

alg

o-rit

hmtra

uma

patie

nts

with

non

spin

al in

jurie

s3

1.00

0

Hol

ly e

t al.,

200

22

US

Leve

l I tr

aum

a ce

nter

sre

trosp

ectiv

e ob

serv

atio

nal

head

inju

ry w

ith G

CS

scor

es 3

–12,

or G

CS

scor

es >

12

with

CT

abno

rmal

ity24

0.58

3

Mac

Don

ald

et a

l., 1

990

sing

le C

anad

ian

Leve

l I tr

aum

a ce

nter

retro

spec

tive

obse

rvat

iona

lm

otor

veh

icle

acc

iden

t tra

uma

adm

issi

ons

920.

174

Mat

hen

et a

l., 2

007

sing

le U

S Le

vel I

trau

ma

cent

erpr

ospe

ctiv

e ob

serv

atio

nal

patie

nts

with

nec

k pa

in, n

euro

logi

cal d

efic

it, o

r int

oxic

a-tio

n60

0.25

0

Rei

d et

al.,

198

7si

ngle

Can

adia

n Le

vel I

trau

ma

cent

erre

trosp

ectiv

e ob

serv

atio

nal

coho

rt of

pat

ient

s w

ith k

now

n C

SIs

253

0.34

8

Ros

s et

al.,

199

2si

ngle

US

Leve

l I tr

aum

a ce

nter

pros

pect

ive

obse

rvat

iona

lbl

unt t

raum

a ad

mis

sion

s43

0.30

2Sc

hena

rts e

t al.,

200

1si

ngle

US

Leve

l I tr

aum

a ce

nter

pros

pect

ive

eval

uatio

n of

clin

ical

alg

o-rit

hmal

tere

d m

enta

l sta

tus

afte

r blu

nt tr

aum

atic

inju

ry70

0.17

1

Slik

er e

t al.,

200

5m

ultip

le L

evel

I tra

uma

cent

ers

retro

spec

tive

liter

atur

e re

view

obtu

nded

blu

nt tr

aum

a pa

tient

s16

50.

612

Spite

ri et

al.,

200

6si

ngle

UK

traum

a ce

nter

retro

spec

tive

eval

uatio

n of

clin

ical

al

gorit

hmtra

uma

adm

issi

ons

unde

rgoi

ng c

ervi

cal C

T95

0.91

6

Wid

der e

t al.,

200

4si

ngle

Can

adia

n Le

vel I

trau

ma

cent

erpr

ospe

ctiv

e ob

serv

atio

nal

obtu

nded

blu

nt tr

aum

a pa

tient

s18

0.00

0

Yana

r et a

l., 2

007

2 U

S Le

vel I

trau

ma

cent

ers

retro

spec

tive

obse

rvat

iona

lpe

dest

rians

inju

red

by a

utom

obile

s17

80.

242


A. H. Milby et al.


were selected with information on the prevalence of CSI or the proportion of instability in CSI.3,4,8–11,14,16,17,21,23,26,31–

40,42–44,47,48,52–57,62,63,66,68–70,73,74,78,79,81,84,86,88,92,93,95,97,98 Twenty-nine of these reports included 209,320 patients who sus-tained nonspecific trauma and were not categorized by level of consciousness (Table 1). Nine series with 21,286 cases pertained specifically to alert patients with reliable clinical examination findings (Table 2). Twenty series contained 49,938 unconscious or obtunded patients who met our criteria for unevaluable (Table 3). Twenty-one se-ries composed of 3555 patients with known CSI reported data on the proportion of these injuries considered to be unstable (Table 4; Fig. 1). Tables 1 through 4 analyze the evidentiary characteristics of these series.

The overall prevalence of CSI in all trauma patients was 3.7% (Tables 1 and 5). In alert patients only, the prevalence of CSI was 2.8% (Tables 2 and 5). Clinically unevaluable patients were found to be at increased risk of CSI with a prevalence of 7.7% (Tables 3 and 5). Once detected, 41.9% of all CSI were subsequently determined to be unstable (Tables 4 and 5). The difference in preva-lence of CSI between the alert and unevaluable groups was statistically significant, with unevaluable patients at a significantly greater risk for CSI than alert patients (p = 0.0072).

DiscussionOur findings demonstrate a higher prevalence of CSI

in clinically unevaluable patients with trauma compared with alert patients with trauma. Hence, this high-risk pa-tient population may be subject to increased occult un-stable injuries. The potential for quadriplegia following CSI that is undiagnosed underscores the importance of detecting such injuries, but it is unknown whether the

use of advanced imaging techniques for cervical spinal clearance is cost effective when compared with prolonged semirigid collar immobilization. A more precise quan-tification of the prevalence of CSI in these populations allows us for the first time to make evidence-based deci-sions in guiding large-scale resource utilization. It is our expectation that these prevalence figures will aid in the calculations needed for indicated cost-effectiveness stud-ies.

There are several important limitations to this study. Many of these limitations are inherent to the technique of meta-analysis, and are the result of variations in the definition of certain clinical terms used by articles that met our inclusion criteria. Most notable of these is the distinction between alert and unevaluable trauma patient populations. Every attempt was made to categorize the included studies systematically, although the existence of minor disparities between study populations is acknowl-edged. Authors also differed as to whether the overall trauma populations included patients with penetrating trauma or were restricted to those with blunt trauma. The regional variability in rates of penetrating trauma limits the generalizability of these data to all trauma centers, although these rates were invariably quite low.

ConclusionsTrauma patients who are clinically unevaluable have

a higher prevalence of CSI than alert patients. Detection of CSI in this population is especially challenging, and places these patients at increased risk for cervical insta-bility and quadriplegia. Knowledge of the prevalence and risk of such injuries may help establish an evidence-based approach to the detection and management of clinically occult CSI.

Disclaimer

The authors report no conflict of interest concerning the mate-rials or methods used in this study or the findings specified in this paper.

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Fig. 1. Flow chart showing the evidentiary value with regard to prev-alence of CSI in publications fulfilling the initial search criteria. Bold numbers represent the number of publications in each category.

Table 5: Pooled prevalences of CSIs*

Patient PopulationNo. of

PatientsPooled

Mean (%) 95% CI

all trauma 209,320 3.68 3.64–3.72alert patients 21,286 2.78 2.74–2.81unevaluable patients 49,938 7.66 7.59–7.81proportion of unstable injuries

3,555 41.87 41.46–42.28

* CI = confidence interval.




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Manuscript submitted July 14, 2008.Accepted July 29, 2008.Address correspondence to: Sherman C. Stein, M.D., Hospital

of the University of Pennsylvania, Department of Neurosurgery, 3 Silverstein, 3400 Spruce Street, Philadelphia, Pennsylvania 19104. email: [email protected].


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