Cervical spine clearance in trauma patients

Injuries to the cervical spine occur in approximately 4% of trauma patients, including 8% of patientswho are unconscious or obtunded, and 3% of alert trauma presentations. Failure in detecting cervical spine injury in an efficient and timely manner in the acute clinical setting can result in catastrophic consequences involving permanent neurologic sequelae. As a result, clinical assessment and radiographic screening protocols exist in order to expedite the identificationof primary cervical spine injury promptly, and to protect the patient against secondary injury which may have the potential to compromise spinal integrity. The presence of cervical spine injury is frequently demonstrated by the existence of neurologic deficit or via positive radiographic findings. However, in other cases, where there is no evidence of fracture or malalignment, orwhen the patient is unable to contribute to clinical assessment due to decreased mentation, the signs and symptoms of cervical spine injury may be subtle. While initial clinical assessment is generally conducted using one of the most commonly used evidence-based decision rules, the National Emergency X-radiography Utilisation Study (NEXUS) criteria, the Canadian C-spine Rule (CCR) or the Harborview Criteria, there is continuing debate about the optimal radiographic imaging protocol when clinical clearance alone, according to these assessment criteria, is not possible. Randomised controlled trials have not been conducted to compare imaging strategies for cervical spine clearance due to ethical considerations regarding patient safety in these patient populations, and as such, current protocols are informed by observational studies, of which few are prospective cohort studies. This narrative review seeks to