Introduction: Cervical spine injury (CSI) occurs in 2-4% of trauma patients in the USA causing significant decrements in quality of life and even death. Treatment of CSI is estimated to cost $9.7 billion annually. Computed tomography (CT) has an almost 100% negative predictive value (NPV) for cervical spine (c-spine) clearance, in both alert and obtunded patients. However, MRI can depict occult discoligamentous injury in some patients with negative CT scans. It remains unclear whether MRI findings should preclude c-spine clearance and prolong hospital stay. This review intends to critically assess CT-missed CSI patients and derive a safe, economically sustainable protocol for c-spine clearance.

Methods: A retrospective review of prospectively collected CSI data from two, level-1 trauma centers, was conducted from 2015-2016. Primary outcome measures include: NPV and the incremental cost-effectiveness ratio (ICER) of a novel c-spine clearance protocol compared with standard of care. The protocol included thin-cut CT scans with either weight-bearing or flexion-extension films. The ICER was calculated using standard cost-utility analysis techniques in US dollars ($) per quality-adjusted-life-year (QALY), assuming a willingness-to-pay threshold of 50,000 $/QALY.

Results: A total of 614 patients were reviewed. Mean age was 38.3 years (SD 18.6), 147 (23.9%) had altered mentation, and 12 (2%) had clinically meaningful CT-missed acute discoligamentous disruption. Our c-spine clearance protocol had a NPV of 99.8% (CI 96.5-100%). There was no statistically significant difference between awake and obtunded patients (p=0.74). Mean time to c-spine clearance improved by 1.3 days (SD 0.9). Duration of c-spine immobilization was reduced by 930 person-days. Mean cost savings was $1230 (SD $242) per patient. Mean change in QALY was 0.02 (SD 0.01). The ICER was –61,500 $/QALY.

Conclusions: Our novel CSI clearance protocol is both safe and highly cost-effective. It improves outcomes at less cost, making it a dominant strategy that centers should consider implementing.

Patient Care: The cervical spine can be safely and efficiently cleared in trauma patients by following a protocol that eliminates the need for MRIs in most instances. This will reduce costs while mitigating the time patients spend in scanners and wearing collars. Individual and societal benefits appear to be substantial.

Learning Objectives: By the conclusion of this session participants should be able to: 1) Describe the important of cost-effectiveness in spine trauma management; 2) Discuss in small groups practice patterns for safely clearing the cervical spine in trauma; and, 3) Identify an effective treatment for clearing the cervical spine in trauma patients that does not rely on unsustainable practices, such as ordering MRIs on everyone.

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