A scoping review of cervical spine evaluation in standardised clinical concussion evaluation tools
Introduction
Concussion is described as “… a traumatic brain injury, induced by biomechanical forces” (p.839) with signs and symptoms that cannot be explained by other issues such as cervical spine injury (McCrory et al., 2017). It presents a challenge for clinicians to evaluate trauma that could reasonably result in cervical spine injury, concussion, or both. These conditions share a common mechanism of injury, symptom profile (e.g. headaches, dizziness) and clinical presentation (Cheever, Kawata, Tierney, & Galgon, 2016; Elkin, Elliott, & Siegmund, 2016; King, McCrea, & Nelson, 2020; Leddy et al., 2015). Yet, there is a strong need to differentiate. Concussion and cervical spine dysfunction represent distinct fields each with their own evidence regarding aetiology, evaluation and management. This distinction is reflected in recommendations that the cervical spine should be considered in suspected concussion, and that this should influence management (Ellis, Leddy, & Willer, 2015; McCrory et al., 2017; Schneider, 2019; Zasler, Haider, Grzibowski, & Leddy, 2019). What is less clear is how best to consider the cervical spine when evaluating suspected or confirmed concussion.
Although the cervical spine is acknowledged as a potential source of symptoms in concussion (McCrory et al., 2017), no clear guidelines currently exist for the evaluation of the cervical spine post-concussion (Leddy et al., 2015). Clinicians are supported by evaluation tools such as the Sport Concussion Assessment Tool 5 (SCAT5), an example of an internationally recognised standardised evaluation tool for suspected concussion used by health professionals. This provides guidance in evaluating sports-related concussion, supplementing rather than replacing clinical judgement. Yet the extent to which the SCAT5 supports clinicians to appropriately evaluate cervical spine injuries is unclear. Other standardised concussion evaluation tools may offer alternative approaches. It would be unreasonable to expect that tools designed for concussion evaluation should provide comprehensive cervical spine evaluation. Yet tools could be expected to offer sufficient guidance to identify clinically significant cervical spine injuries in acute settings, and identify potential cervical spine injury in non-acute settings. A summary of how a range of standardised concussion evaluation tools consider the potential for cervical spine injury in suspected concussion would offer insight into how health professionals involved in concussion care currently evaluate these conditions.
In line with a key indication for scoping reviews described by Munn et al. (2018), this review aims to identify key characteristics related to a concept: specifically, to identify the characteristics of cervical spine evaluation included in standardised concussion evaluation tools. This will inform a discussion about how cervical spine evaluation might best be approached in people with suspected or confirmed concussion.
Section snippets
Methods
A three-step process was taken to address the research question (Fig. 1). This involved: 1. A structured search strategy to identify standardised concussion evaluation tools; 2. A review of evaluation tools to check if cervical spine evaluation were included; and 3. A descriptive analysis of the characteristics of tools including cervical spine evaluation. The structured search strategy followed guidelines described by Peters et al. (2015) based on the Joanna Briggs Institute.
Results
The results of the literature search are shown in Fig. 2, in a PRISMA Flow Diagram for scoping reviews (Peters et al., 2015). Duplicates were removed after screening by title. The search returned 10,126 records from which 322 items were included. A further 28 records were found with a manual search of references.
A total of 82 standardised concussion evaluation tools were identified from included articles (Table 1). A cross-reference list showing how the search identified assessment tools is
Discussion
This review identifies numerous standardised concussion evaluation tools, yet few that include cervical spine evaluation. Tools identified were diverse, reflecting the complex nature of concussion and efforts to identify a wide range of issues following a concussive event. Just 11 of 82 tools identified (13%) included a cervical spine evaluation component. This indicates that potential cervical spine injury is either not considered or is considered separately from concussion evaluation tools.
Limitations
This study focuses on identifying standardised clinical concussion evaluation tools utilised in published literature, excluding perspectives that may be found in opinion and guideline articles as well as cervical spine specific literature. The large volume of concussion related literature required substantial screening. Preliminary work indicated that narrower search terms excluded tools of interest, so a decision was made to proceed with a more comprehensive search and have a single reviewer
Conclusion
Clinicians involved in the evaluation of suspected concussion should consider how best to include evaluation of the cervical spine as part of care. Few standardised clinical concussion evaluation tools include cervical spine evaluation, and even fewer include physical examination. Cervical spine evaluation in concussion may benefit from closer alignment with established approaches to screening for clinically significant cervical spine injuries such as the Canadian C-spine Rule and NEXUS
Ethical approval
Ethical approval was not required prior to undertaking this review.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interest
None declared by each author.
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