Cervical spine clearance is always a fun topic. Once upon a time, it was plain radiography, clinical re-assessment, and functional testing with dynamic radiography. Now, a zero miss culture has turned us mostly to CT – and, beyond that, even some advocate for MRI.
But, as far as clinical clearance of the cervical spine goes, we usually use the NEXUS criteria or the Canadian C-Spine criteria. One of the elements of the NEXUS criteria that is, essentially, subjectively defined is the presence of "distracting injury". Many have questioned the inclusion of this element.
These authors looked at cervical spine clearance in the presence of "distracting injury", which, for the purpose of research protocols, was essentially a fracture somewhere, an intracranial injury, or an intra-abdominal organ injury. They found, when assessing a GCS 14 or 15 trauma patient, even in the presence of these other injuries, clinical examination picked up 85 of 86 cervical spine injuries. One patient did not report midline cervical spine tenderness – with humerus and mandible fractures, as well as frontal ICH – and had a 2nd vertebrae lateral mass fracture.
So, clinical examination is mostly reliable in the presence of a "distracting injury". I think the best interpretation of this study is "distracting injury" has to be determined on a case-by-case basis – one patient might be a reliable reporter in the presence of long-bone fracture, while another might need such a high level of pain control for initial management they are no longer aware of their cervical spine injury. It's fairly clear it is reasonable to remove the cervical collar and forgo imaging for most patients who can be adequately clinically assessed.
"Clinical clearance of the cervical spine in patients with distracting injuries: It is time to dispel the myth"