Posted: December 21st, 2014

An Investigation of the Use of Computed Tomography scan as Compared to Magnetic Resonance Imaging in the Evaluation of Cervical Spinal Injuries in Obtunded Patients.

Topic: An Investigation of the Use of Computed Tomography scan as Compared to Magnetic Resonance Imaging in the Evaluation of Cervical Spinal Injuries in Obtunded

Patients.

Title: An Investigation of the Use of Computed Tomography scan as Compared to Magnetic Resonance Imaging in the Evaluation of Cervical Spinal Injuries in Obtunded

Patients.

A Protocol for a Structured Literature Review.

4,000 Words

The title of the module, including the academic level
The title of your programme
The title of your assessment
Student’s full name
Matriculation number
Name of Module Leader
Date of submission
Word count

Contents
Abstract.
Introduction.
Literature review: Justification.
Research Question.
Research Aims.
Perspective and Methodology.
Methodology of literature search.

Inclusion and exclusion criteria.
Methods: Quality Assessment.
Data extraction tool and data analysis.
Data Extraction Tool.
Timetable.
Budget and likely funding sources.
Dissemination of results.
References.

Appendix 1
Quantitative Research Papers Critiquing Tool
Appendix 2
Classification of evidence levels
Appendix 3
Search results
Appendix 4
Inclusion/Exclusion criteria

Proposal
To the writer: I would like to replace whole the abstract by a new one .Please follow the attached guidelines and it is better to divided the abstract to two

subheadings
Abstract
This proposal is for a systematic review which considers the evidence base comparing the clinical utility of CT scans and MRI scans in the evaluation of cervical

spinal injuries in obtunded patients. The proposal starts with a brief introduction which considered the background to the historical data and some of the current

position literature which compares MRI and CT modalities. It then explores the justification and the rationale for this study which sets out some of the relative

advantages and shortcomings of both techniques. The research question is posed together with the research aims.
It considers the mechanisms available for exploring the evidence base in this clinical area and considers and weighs the various methodologies available, and presents

the rationale, not only for the topic to be explored, but also for the mechanisms and methodologies which are proposed for this investigation. It is suggested that a

systematic literature review would be the most appropriate format to explore that gap in the evidence base. The results of preliminary literature searches are

presented together with a short overview of the current literature available. Various other parameters of the proposed research are also presented including the

mechanisms for data extraction and analysis, which will be the CASP tool, together with the presumptive timetable over a six month period, the costings and a proposal

for dissemination of results.

Introduction:
For many years the plain X-Ray was the most substantive tool available for evaluating suspected cervical spine injury (CSI) in trauma patients. The advent of CT and

MRI imaging revolutionised the ability of clinicians to determine the presence of occult injury, particularly in the presence of the unconscious or unresponsive

patient. It is still the case however, that some potentially serious injuries can remain undetected, even with all investigative modalities being used (Munera et al.

2012).

It is still the case that the evaluation of the cervical spine in the obtunded trauma patient in the clinical scenario, is a subject fraught with controversy. Even a

brief overview of the literature demonstrates that there is a body of opinion (viz. Healy et al. 2014) which suggests that negative computed tomography (CT) scan is

sufficient for clinical management. Other authorities suggest that a CT scan alone can miss occult unstable injuries and that MRI imaging will alter management.

A particularly large and recent study (Satahoo et al. 2014) supported the view that CT scanning alone did not miss any unstable injuries in a large entry cohort at a

district general trauma unit. In consideration of the costs involved in getting MRIs done on patients who have already had a CT scan, there is obviously an important

consideration in establishing the evidence base to support the view that MRIs may or may not be indicated in the obtunded trauma patient, quite apart from the obvious

connotations of appropriate patient management.

Background :
If one considers a brief overview of the available literature on the subject, it is possible to see that there are several studies which, although not directly

comparative studies, do offer tangential evidence which can be extrapolated to the current research question. As an illustrative example, a major evidence level IIa

study by Como et al. (2011) reported a retrospective study of a moderate cohort (n=197) of obtunded patients who had negative CT imaging for neck injury. These

patients were re-examined after collar removal and some were submitted for MRI scanning. This latter subgroup amounted to 2.5% of the CT scanned population and all

were found to be MRI-negative for neck injury. Only one of the patients, who died of other causes, was found at autopsy to have an unstable neck fracture but this

patient died before their collar was removed. The authors felt able to conclude that a CT scan alone is sufficiently discriminatory for unstable cervical spine injury

in their cohort to the extent that they felt that an MRI was not necessary and introduced further patient risks of unnecessary radiation
Head and neck injury remains a significant cause of death and disability in young adults. Over 50% of such patients will experience unfavourable outcomes (Edwards et

al. 2005). Although this investigation will be primarily aimed at neck injuries, it has to be noted that a great many of the papers in the peer reviewed literature on

the subject are clustered with head injuries. This does have clinical relevance, as clearly in the acute clinical situation the clinicians will want as much

information as possible with the minimum of intervention.
In order to offer a balanced assessment, one can also consider the evidence level Ia study by Schoenfield et al. (2010) study which presented a meta-analysis of trials

which considered the merits of offering an MRI scan after a CT scan. This study started with the premise that a CT scan was considered mandatory and whether an MRI

scan then offered any further clinically useful information. The meta-analysis considered 11 studies and over 1,500 patients who were all obtunded casualty patients

and who had received CT scans, and then subsequently had MRIs. The authors found that 12% of patients who had a CT scan reported as normal had abnormalities on the

MRI. A critical analysis would have to conclude however, that in only 6% of these cases, the abnormality detected altered management decisions. The authors concluded

that although the number of clinically significant missed diagnoses was small, because of the nature of the potential consequences of missed pathology in this area,

reliance on CT imaging alone to determine management of the cervical spine after blunt trauma, can lead to missed injuries. There is then some evidence to support a

role for the use of MRI in patients who are obtunded, or unexaminable, even in the presence of a negative CT scan.

Further evidence comes from an evidence level IV review paper by Brohi (2002) which, although being a personal review of the subject, relies heavily on other

authoritative studies. Although this does not directly compare CTs and MRIs in terms of efficacy, by extrapolation, the information contained is heavily evidence based

and useful in the furtherance of this exploration of the available evidence base. The author advocates examination of the cervical spine in the unconscious, intubated

patient by means of:-
Lateral cervical spine film
Antero-posterior cervical spine film
CT scan of occiput – C3
The author points out that the standard open-mouth odontoid x-ray is inadequate in intubated patients and will miss up to 17% of injuries to the upper cervical spine.

He then suggests that the evidence base (citing Schenarts et al. 2001) supports a “thin-cut (2mm) axial CT scanning on specific bone windows, with sagittal and coronal

reconstruction should be used to evaluate abnormal, suspicious or poorly visualised areas on plain radiology. With technically adequate studies and experienced

interpretation, the combination of plain radiology and directed CT scanning provides a false negative rate of less than 0.1%. The scan should include the entire

vertebral body above and below the region of interest, as these must be undamaged for subsequent internal fixation” (Brohi 2002). In respect of the use of MRI scans,

the author makes a number of valid points, but one has to assess these comments with the knowledge that the paper is now 12 years old. The author point out that MRI is

valuable as it is extremely sensitive at detecting soft tissue injuries without stressing the cervical spine. The significance of soft tissue injuries with regards to

the clinical stability of the spine is not clear. It is the case that the number of false positive examinations is high. One also has to note that the MRI of

ventilated patients is a major undertaking requiring special non-ferromagnetic equipment. He also observes that there have been few good studies on the use of MRI in

clearing the cervical spine in unconscious patients. In congruence with the more recent Como et al. (2011) study, Brohi points out (citing the authority of Chui et al.

2001) that a CT of the full cervical spine has shown it to be a robust investigation, particularly if widening, slippage or rotational abnormalities of the cervical

vertebrae, which suggest soft tissue injury, are considered. The author observes that no published study has missed a cervical spine injury, and no study has

identified an injury on plain films that was not apparent on the CT scan.
It is clear from this representative selection of the available literature that there is a wide body of authoritative opinion on the usefulness of the MRI in these

circumstances. It has also been the purpose of this short segment to present papers of different evidential value, namely an evidence level IIa retrospective study by

Como et al. (2011), an evidence level Ia meta-analysis by Schoenfield et al. (2010) and an evidence level IV study by Brohi (2002), all of which essentially come to

different conclusions when examining the same clinically relevant question. The evidence base in this area is demonstrably not secure. It is for this reason that this

systematic review is proposed to attempt to clarify the situation further.
The consideration is complicated further by the fact that the CT is not a harmless procedure. There is exposure to ionising radiation. Clarke et al. (2001) point out

that the health detriment potentially arising from the radiation dose associated with the CT scan has been quantified in terms of the number of likely cases of serious

health effects. The authors demonstrated that there was a significant saving in the collective radiation dose, with an associated detriment of between 0.23 and 0.33

cases of malignancy or hereditary effects averted in one typical imaging department every year. Therefore in the selection of the balance of provision of MRI and CT

facilities, the health detriment factor associated with the radiation dose from a CT scan should also be considered.

Research Question
What is the evidence base supporting the use of Computed Tomography scans and Magnetic Resonance Imaging in the evaluation of cervical spinal injuries in obtunded

patients?
To the writer: I think that the aims are very general, it is better to add some relevant words from my topic to each one except the 3rd aim
Research aims:
To critically explore the available literature
To determine the evidence base supporting the research question
To identify the gaps in the evidence base.
To draw clinically relevant conclusions from the results of the investigation.
To the writer: Methodology and Methods are in the same paragraph, could you do subheading? Please check guidelines, and check if there is something missing. PICO is

not mention in LiteratureSearch Strategy !!

Perspective and Methodology.
Because a gap in the literature supporting the evidence base can be demonstrated, there is a debate about the best mechanisms for filling that gap.
The results of an investigation are dependent upon the methods chosen to carry out the investigating (Bell 2010). This investigation will be a systematic review of the

peer reviewed literature which therefore requires a specific protocol and procedure in order to reach a valid and robust conclusion. The structure of any given review

will differ depending on the type of research question it needs to answer (Bowling 2002).
Gough et al. (2012) point out that it therefore follows that the nature of the research question effectively determines the structure of the review and the type of

evidence which is included. The aggregated review focusses of the collection and analysis of primary data to provide evidence and to support conclusions. They will

typically have the same rigour any primary assumptions as quantitative research. Brink et al. (2006) make the point that investigations which focus on comparative

healthcare interventions, procedures or diagnoses are particularly appropriate for a quantitative methodology. In essence, this investigation is a comparative

diagnostic accuracy test of the two imaging techniques, an evaluation or “index test” which assesses the comparative diagnostic value of each. Because it simply would

not be considered ethical to construct a randomised controlled trial due to the impossibility of offering patients one or other of the investigations, the results

would be compared against a reference standard which, in most cases would be the radiologists’ interpretations. This consideration results in the majority of available

studies being primary studies with a quantitative design. Quantitative trials have many methodologies all with intrinsic strengths and weaknesses. The designs selected

for inclusion will clearly determine the ultimate reliability and validity of the review. It follows that a critical review will be part of the review process using

the CASP tool (appendix 1) and the SIGN evidence base assessment (appendix 2). Of the various studies considered in the preparation of this review, the diagnostic

cohort study is the preferred design with consecutive patients being subjected to both imaging modalities and the results compared against the radiologist’s

interpretation. This type of study has the advantage that it has great clinical applicability and relevance.
The systematic review is one of the major supports of evidence based medicine. This was introduced and widely accepted as a concept during the 1990s when the

proliferation of research in medicine resulted in a proliferation of a great many studies with low quality and poor methodological designs giving rise to an insecure

evidence base (Cottrell & McKenzie, 2011). Evidence based medicine was defined by Sackett in his landmark paper in 1997 as “conscientious, explicit, and judicious use

of current best evidence in making decisions about the care of individual patients…integrating individual clinical expertise with a critical appraisal of the best

available external clinical evidence” (Sackett 1997 pg 4). The author then went on to expound the value of the systematic literature review in supporting a secure

evidence base with the observation “This should help to improve patient care by ensuring that practice is consistent with the needs of the patient, but also with the

best research currently available” (Sackett 1997 pg 5). Szklo & Nieto (2014) observing that many health care professionals have difficulty in establishing an evidence

base in their clinical area. The systematic review assists in this by offering findings in a specific format which may be directly applied to clinical practice, the

authors having already searched, evaluated, synthesised and presented the most important primary research literature on a given topic (Torgerson, 2003).
Although narrative and thematic reviews may have a greater degree of flexibility in identifying the key themes as they emerge (Jesson et al., 2011), the systematic

review is more in congruence with the principles of evidence-based medicine. By the use of the systematic process to both objectively identify and then evaluate the

evidence which is relevant to a particular clinical area, it should help to achieve findings that are more valid and reliable and reduce the potential for bias (Houser

2013).

The systematic literature review, in the words of Mertens (2005) allows for the development of a theoretical context or framework in order to frame research questions

that use inductive, deductive or mixed methods approaches to the collection of primary and secondary data. Some authorities (viz. Petticrew & Roberts 2006) go so far

as suggesting that the systematic literature review might be appropriate as a research strategy in its own right. The precedent for using the systematic review to

underpin the evidence base in a clinical area is now virtually universally accepted and unassailable (Denyer & Tranfield 2006).

Systematic literature reviews have traditionally been quantitative in approach, presenting a synthesis of findings from a number of individual randomised controlled

trials (Hannes & Macaitis 2012). One has to note the shortcomings of this type of research. Quantitative research is based on positivist philosophy. It typically

provides an objective testing of a hypothesis (Saks & Allsop, 2007). This is particularly useful for gaining an understanding of the efficacy of a clinical

intervention (McQuay 2011). Sole focus on the systematic review and quantitative research could lead to the exclusion of other types of studies which can provide a

greater depth of insight into the clinical area. Qualitative studies which are based on interpretivist paradigm focus instead on the experiences of individual

participants (Saks & Allsop, 2007).
Therefore this systematic review will be presented as a quantitative systematic review, a technique which is best suited to explore the subject area.
In their comprehensive overview of systematic reviews, Khan et al (2003) point out that a review earns the adjective ‘systematic’ if it is underpinned with a clearly

formulated question, it appropriately identifies relevant studies, critically appraises their quality and evidential value and then summarises the evidence extracted

by use of explicit methodology. It is this explicit and systematic methodology which distinguishes systematic review from more traditional literature reviews and

commentaries.
The methodology selected for this review will be to conduct a series of searches across a significant number of specialist databases. The main advantage of using

electronic online databases of the peer reviewed literature is that it provides a comparatively simple method for systematically interrogating a wide range of academic

journal titles for specific keywords. This should help reduce the possibility of researcher bias (Melnyk & Fineout-Overholt 2011). One has to be aware that it is a

disadvantage of this methodology that the databases chosen may not contain all the relevant journal titles. It may therefore exclude some potentially relevant studies

(Polit & Beck 2010). For this reason, the methodology used in this review will require a large number of searches across a substantial number of databases to ensure

maximal capture of information (Garrard 2011). These searches will be carried out at locations which include the University reference library, the local post-graduate

clinical library (client to personalise here) and the online library of the Royal College of Radiologists. Other selected medical databases will also be consulted.

These included Medline, Cinhal, Journals @Ovid Full Text, Ovid, Cochrane, Stanford Hi-wire searchall, Pubmed, PsycInfo, British Journal Of Nursing, Questia, EMBASE

Medicine, The Cumulative Index of Nursing and Allied Health Literature (CINAHL), The online database of the Royal College of Nursing, The Open University, The Lancet,

The British Journal Of Nursing andThe BMJ, (Gravetter & Forzano 2012).

An additional manual search will be made of the grey literature, which tends to be less widely distributed. It will include articles such as dissertations and

unpublished papers. This strategy will also help to overcome publication bias, the tendency of journals and authors to only publish studies which have demonstrated

positive findings (Patel et al. 2013). One has to note that this can be a highly time expensive and resource-consuming approach. A limited snowballing approach to

expand this element of the literature will be used, where relevant articles will be identified from reference lists found in other articles retrieved (Trotter 2012).

The search terms employed will include: magnetic resonance imaging, computed tomography; neck injury; obtund; trauma. These will be used in a variety of different

combinations to interrogate the databases selected. The results of an initial search are shown in Appendix 3

The inclusion and exclusion criteria will be determined to ensure that that the literature search will be efficient, focussed, relevant and time-effective (Saks &

Allsop 2007).

Papers published prior to2000 will be excluded as being too old, unless a specific reason, such as landmark or historical status is found to merit their inclusion.

Inclusion criteria therefore allow studies that have been published in the peer reviewed literature in the English language since 2000 and which are human-based

primary research. They will need to be considered, after critical appraisal, to have made a relevant and appropriate contribution to the evidence base. A number of

other studies will also be retrieved to specifically support a number of the points made in the review.

To the writer: Is the paragraph below important ? many feedbacks on this coursework argued that this paragraph is not important in this stage of research but I will

need it in dissertation! Please check guidelines,appendix 3
This initially resulted in the identification of over 421 articles from the accumulative databases. Many of these studies were duplicated. The duplicates were removed

leaving 41. Application of the inclusion/exclusion criteria reduced this number to 17. These 17 were subject to initial brief screening. A further 9 were excluded for

methodological and evidential reasons. The residual 11 studies were each assigned an evidential level (see appendix 2) and the 5 articles which achieved the highest

evidential values and were published the most recently were then selected to be discussed in the systematic literature review.

Methods: Quality Assessment
Quality assessment is a central and essential element of good quality literature reviews. It clearly follows that if the studies used as the basis for the review have

methodological issues, such as significant elements of bias, then this will reduce the evidential value of the final review (Whiting et al., 2003). Therefore a

critical assessment of each study considered will be included in the methodology of this review. This will be achieved by assessing each study with the CASP tool (see

appendix 1). Each element of the study under scrutiny will be assessed individually and only the highest scoring studies will be progressed through for inclusion into

the literature review. This particular tool has a substantive pedigree, being used (in conjunction with others) in a large number of Cochrane reviews, NICE

publications and the Agency for Healthcare Research and Quality (Rees et al. 2010).

The CASP tool consists of ten main domains, namely; The Abstract/Summary; Introduction/Literature Review Background/rationale; Method Research design; Research

questionnaires; Sample; Ethics; Results/Findings/Data analysis; Discussion; Conclusion and Limitations. Each domain examining the relevance, applicability and rigour

of each element of the target study. In contrast to other tools, such as the QUADAS-2 tool (Whiting et al. 2011), the elements of consideration are not quantitatively

assessed, but are accumulatively assessed by the assessor.

Data extraction tool and data analysis:
The academic concepts of reliability and validity relate mainly to quantitative modes of research, whereas the concepts of consistency, trustworthiness

generalisability and transferability are more prominent in qualitative research (van der Riet & Durrheim 2006). Consistency can generally be evaluated by the

identification of common themes across a number of papers, whereas trustworthiness and transferability can be assessed by critical analysis with a validated tool. The

studies selected for inclusion in this review will be critiqued using the appraisal tool offered by the Critical Appraisal Skills Programme (CASP), which includes a

variety of tools designed for both qualitative and quantitative research (CASP, 2013) (appendix 1)

The data extraction process is an integral part of the study assessment. This process requires the researcher to extract and assimilate the most important and

significant elements of the study, most particularly the essential design features of the study, the demographics of the entry cohort, including the inclusion and

exclusion criteria, the main outcome and results. These would be presented as a synthesised narrative in the review.
In the systematic review proposed, it is anticipated that data extraction will not be a major problem due to the clear direction of the research question and the

clinical specificity of the situation under investigation. It is proposed to construct a data extraction template, which is based on the based on the participants,

interventions, comparisons and outcomes of interest (EPPI Centre London 2008) and this template will be applied to each selected study in turn. It should be noted that

there are a variety of validated approached to data extraction which are available to use. The approach favoured in this circumstance will be the approach recommended

by the CCCRG (2009) in which all themes and other qualitative data which is identified in the primary studies and judged directly relevant to the review question, are

extracted, irrespective of whether or not they are illustrated or supported by a direct quotation. The author suggests that this approach will allow the data

extraction process to be more inclusive. It is accepted that this process also makes it more difficult to critically appraise the validity of the various themes

presented, including how these have been extracted from the data. In congruence with the suggestions of Britten et al. (2010) these issues should be directly presented

transparently in the methodology of the systematic review, so that the readers can make an informed judgment themselves on the matter.
For reasons illustrated in the literature review justification, whereby studies of different evidential value and different methodologies may well come to differing

conclusions, it has been determined that an inclusive approach to data extraction would be adopted to avoid omission of findings which could be of potential value to

the synthesis. Meta-ethnography, as an illustrative example, adopts this approach, by extracting all relevant data presented in a paper, and this includes author

interpretations. If the views are widely supported by the data, then the synthesis will support it, equally if it is not supported, it can be reported with appropriate

caveats in the review (Dixon-Woods et al. 2006).

Part of the rationale for adopting this inclusive approach is whilst noting that it is more comprehensive, it is clearly more resource and time intensive. The

advantages however, not only allow a more complete synthesis of the data, it facilitates further subsequent investigations. This approach is extensively used in the

EPPI Centre which extracts data from all included studies using a universal template (EPPI Centre London 2008) This is subsequently stored in a standardised format so

that, as further evidence is published, it becomes less arduous to incorporate it into the existing data.

Munro et al. (2008) suggest that this technique is helpful when needing to ‘‘deconstruct’’ each study as it facilitates the reconstruction of subsequent studies using

the new included data as well as also facilitating comparison between studies in similar clinical areas.

To the writer: the timetable is confused. Firstly, I am full-time student ,I have 3 months to do the dissertation..Please check the guidelines. Kindly, Explain in

different words than my classmate to avoid peliegirsm
Timetable
Activity    Month
1    2    3     4    5    6
Exploration of the database
Identification of studies
Data collection and extraction
Data analysis
Report-writing and dissemination

It is considered realistic to allow a six month time frame to accomplish this study. The exploration of the database is unlikely to take more than one month, although

it is accepted that repeated visits may become necessary if new information becomes apparent. The extraction, assimilation and analysis of the various studies selected

is thought likely to take a further month and the data extraction process, although possibly running in tandem with the identification process, is inevitably going to

take longer. Data analysis and report writing are thought likely to take about one month each.

Budget and likely funding sources
It is not anticipated that there will be significant expenditure other than on consumables such as stationary and possibly some copying. It is anticipated that the

author will use his own computer and time which will not be charged.

Dissemination of results
Once the studies have been analysed, and the systematic review completed, it will be presented in a format which would be acceptable to the professional peer reviewed

journals. It is anticipated that the resultant review may help to inform both the evidence base, clinicians and other researchers in this area.

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Appendix 1
Quantitative Research Papers Critiquing Tool

A Framework for Critiquing Quantitative Research Papers Include full reference of paper here: (i.e. Author/s (date) Title of article. Journal title. Volume, Number,

page numbers.) Critiquing Framework Title of Paper Is the aim or purpose of the study clear? Are the main variables of interest indicated? Is the study design or

research method clear from the title? Is there any reference to the population from whom the data are collected?

The Abstract/Summary Does this summarise the whole study? Is information provided regarding background, literature, aim/and objectives, hypotheses (if RCT), methods,

sample size, measures used etc, results and conclusions? Does it suggest that a more detailed reading of the rest of the paper would be worthwhile?

Introduction/Literature Review Background/rationale Why was the topic chosen, what is the background to the study? Is there a critical review of previous literature

and related theoretical concepts? Are gaps in the literature identified? Aim and objectives What problem or issue is being investigated? How clearly is this problem or

issue defined or explained? Is there a clearly stated aim? Do the research objectives or research questions support this aim? Are the variables of interest clearly

defined `and are relationships between these evident and clearly stated? Which are the independent and dependent variables? Are hypotheses (if RCT) stated in a way

that makes them testable?

Method Research design What is the study design and is it clearly explained and appropriate for the research questions? Could the design be improved? Was there a pilot

study?

Research questionnaires What measures are used? Are validity and reliability reported for these measures either in the paper or clearly referenced? Have the authors

dealt appropriately with any unreliable questionnaires or scales?

Sample Is the population appropriate for the research question? How were the sample chosen? What is the sample size? Are statistical power considerations discussed?

Are inclusion and exclusion criteria described? Can the results be reasonably generalised on the basis of this sample?

Ethics Are ethical considerations presented. Is it suggested that ethical approval was granted?

Results/Findings/Data analysis Does the paper explain clearly how the data are analysed? Are statistical techniques clearly and adequately described? Are the

statistics presented at a simple descriptive level or are inferential statistics also included? How are the results presented? Does the text adequately explain any

tables or graphs? Have any tests of significance established whether differences, or associations, between groups could have happened by chance? What p values are

used? Are non-significant results clearly indicated?

Discussion Is the discussion an accurate account of the results? Could there be other ways of interpreting the data? Does the discussion address the research aim and

objectives? Are all the research questions answered?

Conclusion Are the conclusions of the study consistent with the results of the statistical analyses? Are alternative conclusions suggested? Are theoretical and

practical implications of the results adequately discussed? Are the recommendations suggested feasible?

Limitations What are the limitations and are these acknowledged by the authors? Overall impression

(CASP 2000)

Appendix 2
Classification of evidence levels
Evidence obtained from meta-analysis of randomised controlled trials.

Ia     Evidence from meta-analysis of randomised controlled trials
Ib    Evidence obtained from at least one randomised controlled trial.
IIa    Evidence obtained from at least one well-designed controlled study without randomisation.
IIb    Evidence obtained from at least one other type of well-designed quasi-experimental study.
III    Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies.
IV    Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities.

(SIGN 2001)

Appendix 3

Search results

Databases    Search Terms    Number of articles found    Limits
Journals @Ovid Full Text    MRI; CT: Neck Injury; obtund; trauma    24    2000 – 2014
Medline,         22
Cinhal        3
Ovid        34
Cochrane        3
EMBASE Medicine        56
Stanford Hi-wire searchall        99
Pubmed        67
The BMJ        54
PsycInfo        0
British Journal Of Nursing        22
Questia,        112
The Cumulative Index of Nursing and Allied Health Literature (CINAHL)        44
The online database of the Royal College of Nursing        23
The Open University        101
The Lancet        18
The British Journal Of Nursing        34
Royal College of Radiologists        44

Appendix 4
Inclusion/Exclusion criteria

Inclusion Criteria    Exclusion Criteria    Rationale
Written in English    Not written English    Unable to read
Research in first world country    Other areas    Relevance to title
Articles written from 2000 to present    Articles before 2000    To get most up to date research.
Primary evidence    Secondary evidence    Best evidence
Human studies only    Non-human studies    Relevance to investigation
Published in peer-reviewed literature     Not published in peer-reviewed literature     Quality of study
Qualitative studies    Quantitative studies    Most appropriate paradigm
Non-duplicated studies    Duplicated studies    Duplicates removed
Above evidence level IIb study    Below evidence level III study    Quality of study

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