Management of patients with cervical spine trauma in the emergency department: a systematic critical appraisal of guidelines with a view to developing standardized strategies for clinical practice

Several guidelines on the evaluation of patients with suspected cervical spine trauma in the Emergency Department (ED) exist. High heterogeneity between different guidelines has been reported. Aim of this study was to find areas of agreement and disagreement between guidelines, to identify topics in which further research is needed and to provide an evidence-based cervical spine trauma algorithm for ED physicians. The three most relevant guidelines published on cervical spine trauma in the last 10 years were selected screening websites of the main scientific societies and through the comparison of a normalized Google Scholar and SCOPUS citation index. We compared the selected guidelines through seven a-priori defined questions. In case of disagreement between the guidelines or if the quality of evidence appeared low, evidence from published systematic reviews on the topic was added to build an evidence-based algorithm for approach to spinal trauma in the ED. The three selected guidelines were: NICE 2016, Eastern Association for the Surgery of Trauma 2009 and American Association of Neurological Surgeons and Congress of Neurological Surgeons 2013. We found complete agreement on one question, partial agreement for one questions, no agreement for two questions, while agreement was not assessable for 3 questions. The agreement between different guidelines and the evidence on which recommendations are based is low. An attempt to build an evidence-based algorithm has been made. More studies are needed on many topics.

Computed tomography-occult discoligamentous instability following blunt cervical spine trauma

Plain CT is routinely ordered following blunt trauma of the cervical spine, and performs well in the exclusion of significant bony injuries. MRI is reserved for cases of suspected neural or posterior ligamentous compromise, and when other imaging modalities are contraindicated. There are patients however, with unremarkable radiology, and without suggestive clinical features, who are later found to have significant discoligamentous instability. In this report, we present two such cases. In both instances, worsening neurological symptoms prompted follow-up imaging, that demonstrated interval development of sub-axial cervical spondylolisthesis, requiring surgery and instrumentation. We identify and discuss radiological features that may be associated with occult discoligamentous injury, and highlight them as avenues for future research. These may prove useful in stratifying at-risk patients for further imaging in the acute setting.