MRI or NOT to MRI
(systematic review)
CT alone is enough to clear C spine in blunt trauma patients with no motor
weakness.
M Azam Majeed, M Ashraf.
Background:
Cervical (C)-spine clearance protocols exist both to identify traumatic injury and to
expedite rigid collar and blocks removal. In the past we all have used C spine X rays
to clear it. It still is taught in trauma life support courses across the world. With
advancing technology, being readily available in major trauma centers, its been
replaced by the Computed tomography (CT) of the C-spine. It facilitates the removal
of immobilization collars in patients who are neurologically intact. Occasionally
patients have a normal CT of the spine but they do have some suttle neurological
impairment and then magnetic resonance imaging (MRI) is an indispensable adjunct
for evaluating these patients. MRI is a brilliant adjunct to identify spinal cord and
ligamentous injuries. There is some published evidence to suggest that these patients
with little neurology can be followed up in a week time and re-assessed, as it could
just be neuropraxia but there isn’t a clear policy that can be followed.
Objective:
Reviewing the literature, to evaluate the incidence of positive MRI, in patients with
normal CT and no motor deficit.
Hypothesis:
Normal CT with no motor deficit doesn’t miss clinically significant injuries.
Method:
We conducted a literature search and found 3 papers1,2,3 relevant to our question.
Results:
Three studies encompassing 3,490 patients met the inclusion criteria. Two of them
were conducted in Level 1 and one was conducted at level 2 trauma center. One was
prospective and two were retrospective studies. The outcome measure of change in
management by the MRI (P < 0.0001) was clinically insignificant.
Conclusion:
Our results are very clear regarding blunt trauma patients, with normal motor
examination and normal CT results, of the cervical spine that they do not require
further radiologic examination before clearing the cervical spine. With the advancing
technologies the 64-slice CT missed no injuries (0%)4. Reliance on CT imaging alone,
to "clear the cervical spine" after blunt trauma, doesn’t miss clinically significant
injuries. Our results support the hypothesis that normal CT with no motor deficit
doesn’t miss clinically significant injuries.
Refrences:
1. Magnetic resonance imaging is not needed to clear cervical spines in blunt
trauma patients with normal computed tomographic results and no motor
deficits. Schuster R, Waxman K, Sanchez B, Becerra S, Chung R, Conner S,
Jones T. Arch Surg. 2005 Aug;140(8):762-6.
2. Clinical outcomes of magnetic resonance imaging in blunt cervical trauma.
Labattaglia MP, Cameron PA, Santamaria M, Varma D, Thomson K, Bailey
M, Kossmann T. Emerg Med Australas. 2007 Jun;19(3):253-61.
3. The value of cervical magnetic resonance imaging in the evaluation of the
obtunded or comatose patient with cervical trauma, no other abnormal
neurological findings, and a normal cervical computed tomography. Khanna
P, Chau C, Dublin A, Kim K, Wisner D. J Trauma Acute Care Surg. 2012
Mar;72(3):699-702. doi: 10.1097/TA.0b013e31822b77.
4. Computed tomography versus magnetic resonance imaging for evaluation of
the cervical spine: how many slices do you need? Brown CV, Foulkrod KH,
Reifsnyder A, Bui E, Lopez I, Hummell M, Coopwood B. Am Surg. 2010
Apr;76(4):365-8.