Clearing the cervical spine in critically injured patients: a comprehensive C-spine protocol to avoid unnecessary delays in diagnosis

Value of MRI in the cervical spine imaging series of trauma patients: A state-of-the-art review

INTRODUCTION

Clinical decision protocols for evaluation and assessment of traumatic cervical spine injuries (TCSI) lean more towards the use of CT imaging. Investigation with MRI is therefore considered unnecessary following negative CT findings according to some local protocols. This review aims to explore what benefits MRI may offer in the clinical management of TCSI patients.

METHODS

A systematic search of the literature was conducted in the following databases: AMED, CINAHL, EMBASE and MEDLINE using defined key terms and synonyms optimised for each database. The eligible articles were subjected to data extraction and thematic synthesis.

RESULTS

The initial electronic search yielded 2527 articles. Of these, 15 articles remained following the application of a pre-defined inclusion criteria and full-text assessment. Four themes (mechanism of injury, type of patient, injuries detected on MRI, significance of injuries detected on MRI) were developed relating to the usage and value of MRI in the management of CSI.

DISCUSSION

Our findings indicate that MRI may be very valuable in some situations for the evaluation of TCSI, however, its usage must be cautiously considered on a case-by-case basis in light of additional clinical benefit, patient safety and resource availability following a normal CT scan or in conjunction with CT or projection radiography where appropriate.

IMPLICATIONS FOR PRACTICE

MRI may serve as a confirmatory test in the management pathway of TCSI based on individual clinical needs. Consideration for key limitations (e.g., patients' cooperation) and accessibility challenges (e.g., cost) against the clinical benefit to the patient must be noted. Development of centre-specific policies from standard trauma imaging protocols may be essential for the timely management of TCSI.

Triage tools for detecting cervical spine injury in paediatric trauma patients

BACKGROUND

Paediatric cervical spine injury (CSI) after blunt trauma is rare but can have severe consequences. Clinical decision rules (CDRs) have been developed to guide clinical decision-making, minimise unnecessary tests and associated risks, whilst detecting all significant CSIs. Several validated CDRs are used to guide imaging decision-making in adults following blunt trauma and clinical criteria have been proposed as possible paediatric-specific CDRs. Little information is known about their accuracy.

OBJECTIVES

To assess and compare the diagnostic accuracy of CDRs or sets of clinical criteria, alone or in comparison with each other, for the evaluation of CSI following blunt trauma in children.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE, Embase, and six other databases from 1 January 2015 to 13 December 2022. As we expanded the index test eligibility for this review update, we searched the excluded studies from the previous version of the review for eligibility. We contacted field experts to identify ongoing studies and studies potentially missed by the search. There were no language restrictions.

SELECTION CRITERIA

We included cross-sectional or cohort designs (retrospective and prospective) and randomised controlled trials that compared the diagnostic accuracy of any CDR or clinical criteria compared with a reference standard for the evaluation of paediatric CSI following blunt trauma. We included studies evaluating one CDR or comparing two or more CDRs (directly and indirectly). We considered X-ray, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and clinical clearance/follow-up as adequate reference standards.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for relevance, and carried out eligibility, data extraction and quality assessment. A third review author arbitrated. We extracted data on study design, participant characteristics, inclusion/exclusion criteria, index test, target condition, reference standard and data (diagnostic two-by-two tables) and calculated and plotted sensitivity and specificity on forest plots for visual examination of variation in test accuracy. We assessed methodological quality using the Quality Assessment of Diagnostic Accuracy Studies Version 2 tool. We graded the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included five studies with 21,379 enrolled participants, published between 2001 and 2021. Prevalence of CSI ranged from 0.5% to 1.85%. Seven CDRs were evaluated. Three studies reported on direct comparisons of CDRs. One study (973 participants) directly compared the accuracy of three index tests with the sensitivities of NEXUS, Canadian C-Spine Rule and the PECARN retrospective criteria being 1.00 (95% confidence interval (CI) 0.48 to 1.00), 1.00 (95% CI 0.48 to 1.00) and 1.00 (95% CI 0.48 to 1.00), respectively. The specificities were 0.56 (95% CI 0.53 to 0.59), 0.52 (95% CI 0.49 to 0.55) and 0.32 (95% CI 0.29 to 0.35), respectively (moderate-certainty evidence). One study (4091 participants) compared the accuracy of the PECARN retrospective criteria with the Leonard de novo model; the sensitivities were 0.91 (95% CI 0.81 to 0.96) and 0.92 (95% CI 0.83 to 0.97), respectively. The specificities were 0.46 (95% CI 0.44 to 0.47) and 0.50 (95% CI 0.49 to 0.52) (moderate- and low-certainty evidence, respectively). One study (270 participants) compared the accuracy of two NICE (National Institute for Health and Care Excellence) head injury guidelines; the sensitivity of the CG56 guideline was 1.00 (95% CI 0.48 to 1.00) compared to 1.00 (95% CI 0.48 to 1.00) with the CG176 guideline. The specificities were 0.46 (95% CI 0.40 to 0.52) and 0.07 (95% CI 0.04 to 0.11), respectively (very low-certainty evidence). Two additional studies were indirect comparison studies. One study (3065 participants) tested the accuracy of the NEXUS criteria; the sensitivity was 1.00 (95% CI 0.88 to 1.00) and specificity was 0.20 (95% CI 0.18 to 0.21) (low-certainty evidence). One retrospective study (12,537 participants) evaluated the PEDSPINE criteria and found a sensitivity of 0.93 (95% CI 0.78 to 0.99) and specificity of 0.70 (95% CI 0.69 to 0.72) (very low-certainty evidence). We did not pool data within the broader CDR categories or investigate heterogeneity due to the small quantity of data and the clinical heterogeneity of studies. Two studies were at high risk of bias. We identified two studies that are awaiting classification pending further information and two ongoing studies.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine the diagnostic test accuracy of CDRs to detect CSIs in children following blunt trauma, particularly for children under eight years of age. Although most studies had a high sensitivity, this was often achieved at the expense of low specificity and should be interpreted with caution due to a small number of CSIs and wide CIs. Well-designed, large studies are required to evaluate the accuracy of CDRs for the cervical spine clearance in children following blunt trauma, ideally in direct comparison with each other.

The Role of Magnetic Resonance Imaging and Computed Tomography in Spinal Cord Injury

Traumatic injuries of the spine are associated with long-term morbidity and mortality. Timely diagnosis and appropriate management of mechanical instability and spinal cord injury are important to prevent further neurologic deterioration. Spine surgeons require an understanding of the essential imaging techniques concerning the diagnosis, management, and prognosis of spinal cord injury. We present a review in the role of computed tomography (CT) including advancements in multidetector CT (MDCT), dual energy CT (DECT), and photon counting CT, and how it relates to spinal trauma. We also review magnetic resonance imaging (MRI) and some of the developed MRI based classifications for prognosticating the severity and outcome of spinal cord injury, such as diffusion weighted imaging (DWI), diffusion tractography (DTI), functional MRI (fMRI), and perfusion MRI.

Variation in global treatment for subaxial cervical spine isolated unilateral facet fractures

PURPOSE

To determine the variation in the global treatment practices for subaxial unilateral cervical spine facet fractures based on surgeon experience, practice setting, and surgical subspecialty.

METHODS

A survey was sent to 272 members of the AO Spine Subaxial Injury Classification System Validation Group worldwide. Questions surveyed surgeon preferences with regard to diagnostic work-up and treatment of fracture types F1-F3, according to the AO Spine Subaxial Cervical Spine Injury Classification System, with various associated neurologic injuries.

RESULTS

A total of 161 responses were received. Academic surgeons use the facet portion of the AO Spine classification system less frequently (61.6%) compared to hospital-employed and private practice surgeons (81.1% and 81.8%, respectively) (p = 0.029). The overall consensus was in favor of operative treatment for any facet fracture with radicular symptoms (N2) and for any fractures categorized as F2N2 and above. For F3N0 fractures, significantly less surgeons from Africa/Asia/Middle East (49%) and Europe (59.2%) chose operative treatment than from North/Latin/South America (74.1%) (p = 0.025). For F3N1 fractures, significantly less surgeons from Africa/Asia/Middle East (52%) and Europe (63.3%) recommended operative treatment than from North/Latin/South America (84.5%) (p = 0.001). More than 95% of surgeons included CT in their work-up of facet fractures, regardless of the type. No statistically significant differences were seen in the need for MRI to decide treatment.

CONCLUSION

Considerable agreement exists between surgeon preferences with regard to unilateral facet fracture management with few exceptions. F2N2 fracture subtypes and subtypes with radiculopathy (N2) appear to be the threshold for operative treatment.

Diagnostic Imaging in Spinal Cord Injury

In the evaluation of spinal trauma, diagnostic imaging is of paramount importance. Computed tomography (CT), flexion/extension radiographs, and MRI are complementary modalities. CT is typically obtained in the initial setting of spinal trauma and provides detailed information about osseous structures. MRI provides detailed information about structural injury to the spinal cord. Diffusion tensor imaging provides microstructural information about the integrity of the axons and myelin sheaths, but its clinical use is limited. Novel imaging techniques may be better suited for the acute clinical setting and are under development for potential future clinical use.

Odontoid Fractures: A Critical Review of Current Management and Future Directions

Odontoid fractures represent one of the most common and controversial injury types affecting the cervical spine, being associated with a high incidence of nonunion, morbidity, and mortality. These complications are especially common and important in elderly patients, for which ideal treatment options are still under debate. Stable fractures in young patients maybe treated conservatively, with immobilization. Although halo-vest has been widely used for their conservative management, studies have shown high rates of complications in the elderly, and therefore current evidence suggests that the conservative management of these fractures should be carried out with a hard cervical collar or cervicothoracic orthosis. Elderly patients with stable fractures have been reported to have better clinical results with surgical treatment. For these and for all patients with unstable fractures, several surgical techniques have been proposed. Anterior odontoid fixation can be used in reducible fractures with ideal fracture patterns, with older patients requiring fixation with 2 screws. In other cases, C1-C2 posterior fixation maybe needed with the best surgical option depending on the reducibility of the fracture and vertebral artery anatomy. In this paper, current evidence on the management of odontoid fractures is discussed, and an algorithm for treatment is proposed.

Cervical spine clearance in the adult obtunded blunt trauma patient: A systematic review

BACKGROUND

A missed cervical spinal injury could have devastating consequences. Patients with a suspected cervical spinal injury are kept in rigid collars for cervical immobilisation. Prolonged collar use has important clinical implications. A well-defined guideline related to the removal of cervical collars from adult obtunded blunt trauma patients has not been developed.

AIM

We sought to determine if Magnetic Resonance Imaging offered a definitive benefit over Computer Tomography with respect to patient management.

METHOD

We searched Ovid Online, EBSCO, NICE Evidence Journals, Medline, PubMED, BNI, CINAHL and Google Scholar as well as the grey literature. Data extraction and synthesis were performed on studies that compared the radiologic findings and clinical outcomes of Computer Tomography scan and Magnetic Resonance Imaging in this patient group.

RESULTS

There is evidence that supports the safe discontinuation of cervical collar use after a negative multidetector Computer Tomography scan result alone. Magnetic Resonance Imaging may detect a significant number of ligamentous injuries, but such injuries are rarely of clinical significance because they rarely alter clinical management. Its use should be limited to specific circumstances.

CONCLUSION

It is important for institutions to re-examine the latest evidence regarding cervical spinal clearance in order to update their guidelines.

Measurements in cervical vertebrae CT of pediatric cases: normal values

PURPOSE

This study aims to determine the normal limits of atlanto-dental interval (ADI), basion-dens interval (BDI), basion-cartilaginous dens interval (BCDI), and prevertebral soft tissue thickness (PVSTT) according to age groups for normal pediatric cases.

MATERIALS AND METHODS

CT images of 256 pediatric patients aged between 1 and 15 years were retrospectively evaluated. ADI, BDI, BCDI and PVSTT measurements were performed.

RESULTS

Upper normal limit (UNL) values for ADI were 2.65-4.8 mm. UNL values for PVSTT were found to be 6.9 mm at C1 level, 6.7 mm at C2 level, 9.3 mm at C3 level, 14.2 mm at C4 level, 14.1 mm at C5 level, 13.8 mm at C6 level and 12.8 mm at C7 level. The maximum value of BDI in the group with non-ossified os terminale was 12 mm, and in the group with ossified os terminale it was 10 mm. The UNL of BCDI determined for females was 5.1 mm, while the UNL for males was 5.6 mm.

CONCLUSION

We propose the obtained values as the UNL values for ADI, BDI, BCDI and PVSTT on CT images in the pediatric population from 1 to 15 years.

Acute management of cervical spine trauma

Traumatic cervical spine injuries represent a significant cause of morbidity and mortality in sports. Appropriate management of such injuries is critical to minimizing harm and facilitating optimal long-term recovery and outcome. Management strategies begin with emergency preparedness amongst sideline providers and extends to paramedic services and medical teams in the acute care setting. This chapter outlines the principles of treatment across the care continuum, with a primary focus on hospital-based care. Diagnostic imaging and equipment considerations are reviewed, with discussion of corticosteroid administration, therapeutic hypothermia, and traction of the cervical spine. Approaches to cervical spine stabilization and return to play are also detailed, with an emphasis on patient-centered care and individualized treatment approaches to the athlete.

Cervical spine evaluation and clearance in the intoxicated patient: A prospective Western Trauma Association Multi-Institutional Trial and Survey

BACKGROUND

Intoxication often prevents clinical clearance of the cervical spine (Csp) after trauma leading to prolonged immobilization even with a normal computed tomography (CT) scan. We evaluated the accuracy of CT at detecting clinically significant Csp injury, and surveyed participants on related opinions and practice.

METHODS

A prospective multicenter study (2013-2015) at 17 centers. All adult blunt trauma patients underwent structured clinical examination and imaging including a Csp CT, with follow-up thru discharge. alcohol- and drug-intoxicated patients (TOX+) were identified by serum and/or urine testing. Primary outcomes included the incidence and type of Csp injuries, the accuracy of CT scan, and the impact of TOX+ on the time to Csp clearance. A 36-item survey querying local protocols, practices, and opinions in the TOX+ population was administered.

RESULTS

Ten thousand one hundred ninety-one patients were prospectively enrolled and underwent CT Csp during the initial trauma evaluation. The majority were men (67%), had vehicular trauma or falls (83%), with mean age of 48 years, and mean Injury Severity Score (ISS) of 11. The overall incidence of Csp injury was 10.6%. TOX+ comprised 30% of the cohort (19% EtOH only, 6% drug only, and 5% both). TOX+ were significantly younger (41 years vs. 51 years; p < 0.01) but with similar mean Injury Severity Score (11) and Glasgow Coma Scale score (13). The TOX+ cohort had a lower incidence of Csp injury versus nonintoxicated (8.4% vs. 11.5%; p < 0.01). In the TOX+ group, CT had a sensitivity of 94%, specificity of 99.5%, and negative predictive value (NPV) of 99.5% for all Csp injuries. For clinically significant injuries, the NPV was 99.9%, and there were no unstable Csp injuries missed by CT (NPV, 100%). When CT Csp was negative, TOX+ led to longer immobilization versus sober patients (mean, 8 hours vs. 2 hours; p < 0.01), and prolonged immobilization (>12 hrs) in 25%. The survey showed marked variations in protocols, definitions, and Csp clearance practices among participating centers, although 100% indicated willingness to change practice based on these data.

CONCLUSION

For intoxicated patients undergoing Csp imaging, CT scan was highly accurate and reliable for identifying clinically significant spine injuries, and had a 100% NPV for identifying unstable injuries. CT-based clearance in TOX+ patients appears safe and may avoid unnecessary prolonged immobilization. There was wide disparity in practices, definitions, and opinions among the participating centers.

LEVEL OF EVIDENCE

Diagnostic tests or criteria, level II.

Triage tools for detecting cervical spine injury in pediatric trauma patients

BACKGROUND

Pediatric cervical spine injury (CSI) after blunt trauma is rare. Nonetheless, missing these injuries can have severe consequences. To prevent the overuse of radiographic imaging, two clinical decision tools have been developed: The National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian C-spine Rule (CCR). Both tools are proven to be accurate in deciding whether or not diagnostic imaging is needed in adults presenting for blunt trauma screening at the emergency department. However, little information is known about the accuracy of these triage tools in a pediatric population.

OBJECTIVES

To determine the diagnostic accuracy of the NEXUS criteria and the Canadian C-spine Rule in a pediatric population evaluated for CSI following blunt trauma.

SEARCH METHODS

We searched the following databases to 24 February 2015: CENTRAL, MEDLINE, MEDLINE Non-Indexed and In-Process Citations, PubMed, Embase, Science Citation Index, ProQuest Dissertations & Theses Database, OpenGrey, ClinicalTrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Health Technology Assessment, and the Aggressive Research Intelligence Facility.

SELECTION CRITERIA

We included all retrospective and prospective studies involving children following blunt trauma that evaluated the accuracy of the NEXUS criteria, the Canadian C-spine Rule, or both. Plain radiography, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and follow-up were considered as adequate reference standards.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the quality of included studies using the QUADAS-2 checklists. They extracted data on study design, patient characteristics, inclusion and exclusion criteria, clinical parameters, target condition, reference standard, and the diagnostic two-by-two table. We calculated and plotted sensitivity, specificity and negative predictive value in ROC space, and constructed forest plots for visual examination of variation in test accuracy.

MAIN RESULTS

Three cohort studies were eligible for analysis, including 3380 patients ; 96 children were diagnosed with CSI. One study evaluated the accuracy of the Canadian C-spine Rule and the NEXUS criteria, and two studies evaluated the accuracy of the NEXUS criteria. The studies were of moderate quality. Due to the small number of included studies and the diverse outcomes of those studies, we could not describe a pooled estimate for the diagnostic test accuracy. The sensitivity of the NEXUS criteria of the individual studies was 0.57 (95% confidence interval (CI) 0.18 to 0.90), 0.98 (95% CI 0.91 to 1.00) and 1.00 (95% CI 0.88 to 1.00). The specificity of the NEXUS criteria was 0.35 (95% CI 0.25 to 0.45), 0.54 (95% CI 0.45 to 0.62) and 0.2 (95% CI 0.18 to 0.21). For the Canadian C-spine Rule the sensitivity was 0.86 (95% CI 0.42 to 1.00) and specificity was 0.15 (95% CI 0.08 to 0.23). Since the quantity of the data was small we were not able to investigate heterogeneity.

AUTHORS' CONCLUSIONS

There are currently few studies assessing the diagnostic test accuracy of the NEXUS criteria and CCR in children. At the moment, there is not enough evidence to determine the accuracy of the Canadian C-spine Rule to detect CSI in pediatric trauma patients following blunt trauma. The confidence interval of the sensitivity of the NEXUS criteria between the individual studies showed a wide range, with a lower limit varying from 0.18 to 0.91 with a total of four false negative test results, meaning that if physicians use the NEXUS criteria in children, there is a chance of missing CSI. Since missing CSI could have severe consequences with the risk of significant morbidity, we consider that the NEXUS criteria are at best a guide to clinical assessment, with current evidence not supporting strict or protocolized adoption of the tool into pediatric trauma care. Moreover, we have to keep in mind that the sensitivity differs among several studies, and individual confidence intervals of these studies show a wide range. Our main conclusion is therefore that additional well-designed studies with large sample sizes are required to better evaluate the accuracy of the NEXUS criteria or the Canadian C-spine Rule, or both, in order to determine whether they are appropriate triage tools for the clearance of the cervical spine in children following blunt trauma.

The NEXUS criteria are insufficient to exclude cervical spine fractures in older blunt trauma patients

BACKGROUND AND OBJECTIVE

The National Emergency X-Radiography Utilization Study (NEXUS) criteria are used to assess the need for imaging to evaluate cervical spine integrity after injury. The aim of this study was to assess the sensitivity of the NEXUS criteria in older blunt trauma patients.

METHODS

Patients aged 65 years or older presenting between 1st July 2010 and 30th June 2014 and diagnosed with cervical spine fractures were identified from the institutional trauma registry. Clinical examination findings were extracted from electronic medical records. Data on the NEXUS criteria were collected and sensitivity of the rule to exclude a fracture was calculated.

RESULTS

Over the study period 231,018 patients presented to The Alfred Emergency & Trauma Centre, of whom 14,340 met the institutional trauma registry inclusion criteria and 4035 were aged ≥65years old. Among these, 468 patients were diagnosed with cervical spine fractures, of whom 21 were determined to be NEXUS negative. The NEXUS criteria performed with a sensitivity of 94.8% [95% CI: 92.1%-96.7%] on complete case analysis in older blunt trauma patients. One-way sensitivity analysis resulted in a maximum sensitivity limit of 95.5% [95% CI: 93.2%-97.2%].

CONCLUSION

Compared with the general adult blunt trauma population, the NEXUS criteria are less sensitive in excluding cervical spine fractures in older blunt trauma patients. We therefore suggest that liberal imaging be considered for older patients regardless of history or examination findings and that the addition of an age criterion to the NEXUS criteria be investigated in future studies.

C2 Fracture Subtypes, Incidence, and Treatment Allocation Change with Age: A Retrospective Cohort Study of 233 Consecutive Cases

The currently available data on the distribution of C2 fracture subtypes is sparse. This study was designed to identify the proportions of the second cervical vertebra (C2) fracture subtypes and to present age and gender specific incidences of subgroups. A dataset of all patients treated between 2002 and 2014 for C2 fractures was extracted from the regional hospital information system. C2 fractures were classified into odontoid fractures types 1, 2, and 3, Hangman's fractures types 1, 2, and 3, and atypical C2 fractures. 233 patients (female 51%, age 72 ± 19 years) were treated for a C2 fracture. Odontoid fractures were found in 183 patients, of which 2 were type 1, 127 type 2, and 54 type 3, while 26 of C2 fractures were Hangman's fractures and 24 were atypical C2 fractures. In the geriatric subgroup 89% of all C2 fractures were odontoid, of which 71% were type 2 and 29% type 3. There was an increasing incidence of odontoid fractures types 2 and 3 from 2002 to 2014. 40% of C2 fractures were treated surgically. This study presents reliable subset proportions of C2 fractures in a prospectively collected regional cohort. Knowledge of these proportions facilitates future epidemiological studies of C2 fractures.

Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND

With the use of the framework advocated by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group, our aims were to perform a systematic review and to develop evidence-based recommendations that may be used to answer the following PICO [Population, Intervention, Comparator, Outcomes] question:In the obtunded adult blunt trauma patient, should cervical collar removal be performed after a negative high-quality cervical spine (C-spine) computed tomography (CT) result alone or after a negative high-quality C-spine CT result combined with adjunct imaging, to reduce peri-clearance events, such as new neurologic change, unstable C-spine injury, stable C-spine injury, need for post-clearance imaging, false-negative CT imaging result on re-review, pressure ulcers, and time to cervical collar clearance?

METHODS

Our protocol was registered with the PROSPERO international prospective register of systematic reviews on August 23, 2013 (REGISTRATION NUMBER: CRD42013005461). Eligibility criteria consisted of adult blunt trauma patients 16 years or older, who underwent C-spine CT with axial thickness of less than 3 mm and who were obtunded using any definition.Quantitative synthesis via meta-analysis was not possible because of pre-post, partial-cohort, quasi-experimental study design limitations and the consequential incomplete diagnostic accuracy data.

RESULTS

Of five articles with a total follow-up of 1,017 included subjects, none reported new neurologic changes (paraplegia or quadriplegia) after cervical collar removal. There is a worst-case 9% (161 of 1,718 subjects in 11 studies) cumulative literature incidence of stable injuries and a 91% negative predictive value of no injury, after coupling a negative high-quality C-spine CT result with 1.5-T magnetic resonance imaging, upright x-rays, flexion-extension CT, and/or clinical follow-up. Similarly, there is a best-case 0% (0 of 1,718 subjects in 11 studies) cumulative literature incidence of unstable injuries after negative initial imaging result with a high-quality C-spine CT.

CONCLUSION

In obtunded adult blunt trauma patients, we conditionally recommend cervical collar removal after a negative high-quality C-spine CT scan result alone.

LEVEL OF EVIDENCE

Systematic review, level III.

Systematic review of flexion/extension radiography of the cervical spine in trauma patients

INTRODUCTION

The aim of this review was to investigate whether Flexion/Extension (F/E) radiography adds diagnostic value to CT or MRI in the detection of cervical spine ligamentous injury and/or clinically significant cervical spine instability of blunt trauma patients.

METHODS

A systematic search of literature was done in Pubmed, Embase and Cochrane Library databases. Primary outcome was sensitivity and specificity of F/E radiography. Secondary outcomes were the positive predicting value (PPV) and negative predicting value (NPV) (with CT or MRI as reference tests due to the heterogeneity of the included studies) of each modality and the quality of F/E radiography.

RESULTS

F/E radiography was overall regarded to be inferior to CT or MRI in the detection of ligamentous injury. This was reflected by the high specificity and NPV for CT with F/E as reference test (ranging from 97 to 100% and 99 to 100% respectively) and the ambiguous results for F/E radiography with MRI as its reference test (0-98% and 0-83% for specificity and NPV respectively). Image quality of F/E radiography was reported to have 31 to 70% adequacy, except in two studies which reported an adequacy of respectively 4 and 97%.

CONCLUSION

This systematic review of the literature shows that F/E radiography adds little diagnostic value to the evaluation of blunt trauma patients compared to CT and MRI, especially in those cases where CT or MRI show no indication of ligamentous injury.

[Emergency trauma room management in severely and most severely injured patients. A multidisciplinary task]

The treatment of most severely injured patients represents a great challenge for the trauma room team. Besides the time factor, which is a crucial cornerstone of the treatment in general and of the appropriate treatment of life-threatening injuries in particular, minor injuries and non-life-threatening injuries must also be taken into account. For this task, multidisciplinary processes play a paramount role. Advanced Trauma Life Support®, Definitive Surgical Trauma Care and the European Trauma Course represent training concepts, which predefine structured diagnostic and treatment procedures. These concepts allocate the highest treatment priority to injuries that may be immediately fatal for the patient. Besides those life-threatening injuries that are commonly summarised under the term "deathly six", other minor traumas should also be assessed and treated in a structured manner as they may often considerably affect the quality of life after trauma.

Imaging of cervical spine injuries in athletes

Trauma of the cervical spine is one of the most harrowing injuries seen in athletics. Although such injuries are not common, their impact can be devastating. Based on a thorough review of the literature, this article explains the identification of cervical spine trauma and the importance of stability therein. Multiple examples are given highlighting these findings and the way that multiple modalities can be used to asses such injuries. The article concludes with a brief review of the current recommendations as they relate to imaging in the initial assessment of cervical spine trauma.

Lodox/Statscan facilitates the early detection of commonly overlooked extracranial injuries in patients with traumatic brain injury

INTRODUCTION

Traumatic brain injury (TBI) is a common diagnosis in the emergency department. Brain computed tomography (CT) has become a standard diagnostic tool with which to examine TBI patients. Conventional X-rays are ineffective for the evaluation of torso or extremity injuries. In the current study, we attempted to establish a diagnostic modality to evaluate systemically initially unconscious patients in the emergency department with a rapid screening technique characterized by sufficient information, low cost and low radiation exposure.

MATERIALS AND METHODS

From January 2008 to December 2009, patients with diminished level of consciousness received the Lodox/Statscan for evaluation of extracranial injuries were enrolled in this study. The accuracy of this diagnostic modality in detecting torso or extremity injuries in initially unconscious patients was analyzed by comparing the initial diagnosis (by the Lodox/Statscan) with the final diagnosis (confirmed by torso CT scan or after two weeks of follow-up).

RESULTS

There were 1,210 patients with TBI whose extracranial injuries were evaluated by the Lodox/Statscan. After excluding intra-abdominal injuries, the overall sensitivity rates of the Lodox/Statscan in diagnosing torso injuries and extremity injuries were 89.7% and 90.2%, respectively. No long bone fracture was missed by the Lodox/Statscan. The sensitivity and specificity of the Lodox/Statscan in diagnosing long bone fractures were both 100%. Most patients with torso injuries that were missed by the Lodox/Statscan could be managed conservatively without further treatment or complications. All of the missed extremity injuries were distal bone fractures.

CONCLUSION

The Lodox/Statscan can provide benefits for surveying extracranial injuries in patients with diminished level of consciousness. The Lodox/Statscan also emits a notably low dose of radiation and appears to be a relatively inexpensive adjunct to screen torso or extremity injuries in TBI patients.

Reduction of radiation exposure in pediatric patients with trauma: cephalic stabilization improves adequacy of lateral cervical spine radiographs

INTRODUCTION

Plain radiographs continue to play a role in cervical spine clearance. Inadequate radiographs commonly necessitate repeat x-rays or computed tomography imaging (10 × radiation dose). We have used the technique of cephalic stabilization (CS) to improve the results of plain radiographs. Cephalic stabilization lateral radiographs are obtained, with one assistant applying traction to the arms while another placing fingers in the patient's ears and stabilizing the head. This study tests the hypothesis that CS improves visualization of the cervicothoracic junction during lateral cervical spine radiographs.

METHODS

A 2-year review of institutional pediatric trauma registry identified 46 patients with CS, matched 1:3 with controls. Randomized lateral radiographs were evaluated independently by 2 pediatric radiologists to determine adequate visualization of the craniocervical and cervicothoracic junctions. Reviewers were blinded to CS through image cropping.

RESULTS

The proportion of adequate visualization of the cervicothoracic junction was 0.85 for cases with stabilization and 0.60 for controls. Odds of obtaining adequate visualization with stabilization are 3.8 times those without stabilization (P = .001) and were even greater for patients younger than 13 years.

CONCLUSIONS

Cephalic stabilization improves visualization of the cervicothoracic junction in lateral cervical spine radiographs and can reduce radiation exposure in patients who would otherwise require further imaging.

Clinical review: Spinal imaging for the adult obtunded blunt trauma patient: update from 2004

PURPOSE

Controversy exists over how to 'clear' (we mean enable the clinician to safely remove spinal precautions based on imaging and/or clinical examination) the spine of significant unstable injury among clinically unevaluable obtunded blunt trauma patients (OBTPs). This review provides a clinically relevant update of the available evidence since our last review and practice recommendations in 2004.

METHODS

Medline, Embase. Google Scholar, BestBETs, the trip database, BMJ clinical evidence and the Cochrane library were searched. Bibliographies of relevant studies were reviewed.

RESULTS

Plain radiography has low sensitivity for detecting unstable spinal injuries in OBTPs whereas multidetector-row computerised tomography (MDCT) approaches 100%. Magnetic resonance imaging (MRI) is inferior to MDCT for detecting bony injury but superior for detecting soft tissue injury with a sensitivity approaching 100%, although 40% of such injuries may be stable and 'false positive'. For studies comparing MDCT with MRI for OBTPs; MRI following 'normal' CT may detect up to 7.5% missed injuries with an operative fixation in 0.29% and prolonged collar application in 4.3%. Increasing data is available on the complications associated with prolonged spinal immobilisation among a population where a minority have an actual injury.

CONCLUSIONS

Given the variability of screening performance it remains acceptable for clinicians to clear the spine of OBTPs using MDCT alone or MDCT followed by MRI, with implications to either approach. Ongoing research is needed and suggestions are made regarding this. It is essential clinicians and institutions audit their data to determine their likely screening performances in practice.

Spine trauma

Spinal fractures represent 3% to 6% of all skeletal injuries. Spine trauma is a complex diagnostic area in which the radiological assessment is crucial. Plain radiography is often used as the initial diagnostic modality. However, stabilization of the acutely injured spine is a primary concern. In this respect, computed tomography (CT) is vastly superior to plain film in terms of speed and accuracy. In many trauma centers, CT has replaced plain film as the primary modality for evaluation of spinal trauma. Magnetic resonance imaging is not indicated for all cases of spinal trauma but provides detailed information about soft tissue structures including the intervertebral disc, the ligaments, the epidural space, the blood vessels, and the spinal cord. MR imaging provides information on these structures not obtained from other modalities. Patients with spinal cord injury may suffer devastating long-term neurologic deficits, so prompt and efficient spinal imaging guidelines are necessary in all trauma centers.

Diagnostic accuracy, biohazard safety, and cost effectiveness-the Lodox/Statscan provides a beneficial alternative for the primary evaluation of patients with multiple injuries

BACKGROUND

Lodox/Statscan is a new digital X-ray machine with a low dose of radiation exposure that provides rapid, whole-body scans. In the setting of acute trauma management, the importance of image study is well recognized. Here, we report the accuracy of diagnoses made using Lodox/Statscan in patients with multiple injuries. We analyze the cost effectiveness, biohazard safety, and detection rate for treatment using the Lodox/Statscan and evaluate whether it is a viable alternative to the conventional trauma X-ray.

METHODS

We retrospectively reviewed patients who received a Lodox/Statscan between November 2007 and January 2009. All patients who had received both a Lodox/Statscan and a computed tomographic (CT) scan were enrolled. The CT scan was used to make the final diagnosis. The detection rate for treatment, sensitivity, and specificity of the Lodox/Statscan in diagnosis was analyzed.

RESULTS

One hundred eighty-four patients were eligible for the study during the 15-month study period. The detection rates for treatment using the Lodox/Statscan for pneumothorax, pelvic fracture, cervical spine injury, and thoracic-lumbar spine injury were 95%, 96.0%, and 57.1%, and 100%, respectively.

CONCLUSION

In our series, the Lodox/Statscan provided similar quality images and conventional series to the CT scans. Although the Lodox/Statscan missed some injuries, most of the subsequent treatments were not changed. Overall, there were several advantages to using this system, including the short interval of study, low-radiation exposure, and low cost. The Lodox/Statscan could therefore be used as an alternative to the traditional trauma X-ray for evaluation of acute trauma patients.

‘Clearing’ the cervical spine in the unconscious trauma patient

This is a systemic review of the published evidence regarding cervical spine management in unconscious trauma patients. We examine the literature in the following sections: use of plain radiography; use of flexion/extenson views; use of computed tomography; use of magnetic resonance imaging. We also review surveys of practice and current guidelines.

In contrast to the conscious trauma patient there have been no large prospective multicentre studies to derive a clinical decision rule for the exclusion of cervical spine injury. This review therefore assesses currently available evidence to reach a logical conclusion regarding the most appropriate imaging strategy to exclude significant injury in the cervical spine, whilst minimising the time that a patient needs to remain immobilised.

Introduction to reading and clearing cervical spines for advanced practice nurses, Part II: C-spine injuries--causes, cases, and treatments (including CT scan)

Part I of this two-part series discussed the anatomy, radiographic reading, and clearing of the cervical spine for advanced practice nurses. Part II reviews the mechanisms of injury, pathophysiology, diagnostic evaluation, and patient management of the most common cervical spine injuries.

[Imaging of trauma with multi-detector computed tomography]

Diagnosis of trauma-related injuries is a key task in modern radiology. Early, thorough and accurate detection of potentially life-threatening injuries is crucial for fast and targeted initiation of treatment. Conventional radiography (CR) and ultrasound (US) are well-established and still represent the basic diagnostic tools for trauma imaging. However, a number of studies have shown a lower detection rate of injuries for radiography and ultrasound compared with computed tomography (CT). Multi-detector CT (MDCT) with its shorter scan time and increased accuracy has become the gold standard for many indications in trauma imaging. As MDCT has a higher radiation dose, its use should be restricted and carefully indicated especially when dealing with a younger patient population. Careful optimization of imaging parameters has to be performed to minimize exposure and maximize diagnostic safety. Modern MDCT examinations produce a large number of images, which have to be limited to a reasonable number for interpretation. This review article focuses on optimization of examination protocols and on how to handle the flood of images for viewing and archiving.

Trauma of the spine and spinal cord: imaging strategies

Traumatic injuries of the spine and spinal cord are common and potentially devastating lesions. We present a comprehensive overview of the classification of vertebral fractures, based on morphology (e.g., wedge, (bi)concave, or crush fractures) or on the mechanism of injury (flexion-compression, axial compression, flexion-distraction, or rotational fracture-dislocation lesions). The merits and limitations of different imaging techniques are discussed, including plain X-ray films, multi-detector computed tomography (MDCT), and magnetic resonance imaging (MRI) for the detection. There is growing evidence that state-of-the-art imaging techniques provide answers to some of the key questions in the management of patients with spine and spinal cord trauma: is the fracture stable or unstable? Is the fracture recent or old? Is the fracture benign or malignant? In summary, we show that high-quality radiological investigations are essential in the diagnosis and management of patients with spinal trauma.

Diagnostic imaging of cervical spine injuries following blunt trauma: a review of the literature and practical guideline

Patients with a (potential) cervical spine injury can be subdivided into low-risk and high-risk patients. With a detailed history and physical examination the cervical spine of patients in the "low-risk" group can be "cleared" without further radiographic examinations. X-ray imaging (3-view series) is currently the primary choice of imaging for patients in the "low-risk" group with a suspected cervical spine injury after blunt trauma. For patients in the "high-risk"group because of its higher sensitivity a computed tomography scan is primarily advised or, alternatively, the cervical spine is immobilised until the patient can be reliably questioned and examined again. For the imaging of traumatic soft tissue injuries of the cervical spine magnetic resonance imaging is the technique of choice.

Fatality from minor cervical trauma in ankylosing spondylitis

Cervical injury is a serious and often fatal complication of ankylosing spondylitis in the setting of minor trauma. This case report describes a 51-year-old woman with ankylosing spondylitis and a minor trauma who developed severe bradycardia during positioning for x ray. Further diagnostic revealed a hyperextensive fracture of C4 with fragments compressing the cervical medulla. The woman subsequently died from hypoxic brain damage. Reviewing the literature, a high alertness in ankylosing spondylitis and minor trauma with neck immobilisation is emphasised, early diagnosis using cervical spine computed tomography is essential to a favourable outcome, and the mechanism of bradycardia in cervical trauma is discussed.

`Clearing' the cervical spine in conscious trauma patients

This is a systematic review of published evidence regarding management of the cervical spine in conscious and co-operative trauma patients. We examine the literature in the following sections: clinical evaluation of the cervical spine; use of plain radiography; use of additional radiographic views; use of computed tomography; use of magnetic resonance imaging. Finally we consider the elderly and paediatric populations, particularly where there are significant differences compared to the general adult population. This paper also reviews the literature regarding non-medical assessment of the cervical spine. We conclude that there are well-validated decision rules available to guide the clinician, and that each imaging strategy has distinct advantages and disadvantages. Familiarity with these issues provides a sound basis for safe and effective decision-making.

ATLS(R) and damage control in spine trauma

Substantial inflammatory disturbances following major trauma have been found throughout the posttraumatic course of polytraumatized patients, which was confirmed in experimental models of trauma and in vitro settings. As a consequence, the principle of damage control surgery (DCS) has developed over the last two decades and has been successfully introduced in the treatment of severely injured patients. The aim of damage control surgery and orthopaedics (DCO) is to limit additional iatrogenic trauma in the vulnerable phase following major injury. Considering traumatic brain and acute lung injury, implants for quick stabilization like external fixators as well as decided surgical approaches with minimized potential for additional surgery-related impairment of the patient's immunologic state have been developed and used widely. It is obvious, that a similar approach should be undertaken in the case of spinal trauma in the polytraumatized patient. Yet, few data on damage control spine surgery are published to so far, controlled trials are missing and spinal injury is addressed only secondarily in the broadly used ATLS(R) polytrauma algorithm. This article reviews the literature on spine trauma assessment and treatment in the polytrauma setting, gives hints on how to assess the spine trauma patient regarding to the ATLS(R) protocol and recommendations on therapeutic strategies in spinal injury in the polytraumatized patient.

Mortality pattern according to autopsy findings among traffic accident victims in Yazd, Iran

OBJECTIVE

To describe mortality pattern and to determine undiagnosed fatal injuries according to autopsy findings among road traffic accident victims in Yazd, Iran.

METHODS

In this retrospective study, 251 victims of road traffic accidents who were admitted to a tertiary trauma hospital over a two-year period (2006 and 2007) and received medical cares were included. Hospital records were reviewed to gather demographic characteristics, road user type, and medical data. Autopsy records were also reviewed to determine actual causes of death and possible undiagnosed injuries occurred in the initial assessment of the emergency unit or during hospitalization.

RESULTS

There were 202 males (80.5%) and 49 females (19.5%). The mean (+/-SD) age of fatalities was 34.1 (+/-21.5) years. Pedestrian-vehicle accidents were the most common cause of trauma (100 cases, 39.8%). The most common cause of death was central nervous system injury (146 cases, 58.1%). The other causes were skull base fractures (10%), internal bleeding (8%), lower limb hemorrhage (8%), skull vault fractures (4%), cervical spinal cord injury (3.6%), airway compromise (3.2%), and multifactor cases (5.1%), respectively. Thirty-six fatal injuries in 30 victims (12%) mainly contributed to death according to autopsy, but were not diagnosed in initial assessments. The head (72.2%) and cervical spine (13.8%) regions were the two most common sites for undiagnosed injuries.

CONCLUSION

Training courses for emergency unit medical staff with regard to interpreting radiological findings of head and neck and high clinical suspicion for cervical spine injuries are essential to improve the quality of early hospital care and reduce the mortality and morbidity of traffic accident patients.

Normal thickness and appearance of the prevertebral soft tissues on multidetector CT

BACKGROUND AND PURPOSE

Analysis of the prevertebral soft tissue (PVST) is helpful in detecting osseous and ligamentous injuries of the cervical spine. Because the standard of care has shifted from radiographs to multidetector CT (MDCT), a re-examination of the PVST on MDCT images is needed to establish normal values for thickness appropriate for this imaging technique.

MATERIALS AND METHODS

Thickness of the PVST was measured in 192 patients undergoing screening cervical spine MDCT with multiplanar reconstructions as part of a trauma protocol. Patients included in the study were not intubated, had an immobilized cervical spine, had normal findings on cervical spine CT, and did not have a diagnosis of osseous or soft-tissue cervical injury. Exclusion criteria included patients with a congenital or acquired (nondegenerative) abnormality of the cervical spine or PVST.

RESULTS

The upper limits of normal for the thickness of the PVST were 8.5 mm at C1, 6 mm at C2, 7 mm at C3, 18 mm at C6, and 18 mm at C7. The upper limit of normal was not determined for C4 and C5 levels due to variable position of the esophagus and larynx. The smallest variability and calculated SDs were found at C2 and C3.

CONCLUSIONS

The thickness of the PVST is important in the detection of underlying injuries to the cervical spine. We propose the obtained values as the upper limits of normal for PVST thickness on MDCT images in the adult population.

Polytrauma--pathophysiology and management principles

BACKGROUND

Multiple injury results in a complex pathophysiological and immunological response. Depending on the individual injury pattern, the time elapsed after injury, and the systemic "danger response", the surgical treatment has to be modified.

OBJECTIVES

This overview provides new insights in the pathophysiology of the early danger response after polytrauma and outlines the main resulting consequences for surgical management.

RESULTS

First, synchronically to the clinical assessment, life-saving procedures need to be performed rapidly, such as control of massive intra-thoracic or abdominal bleeding and decompression of the chest and brain, as standardized by advanced trauma life support guidelines. During the second phase of "day-one-surgery" damage-control interventions such as debridement, decompression and temporary fracture stabilization are needed to avoid an excessive molecular and cellular danger response. Trauma-adjusted surgical techniques are crucial to limit the systemic response known to put remote organs at risk. In the "vulnerable phase" when the patient's defense is rather uncontrolled, only "second look" debridement to minimize a "second hit" is recommended. After stabilization of the patient as indicated by improvement of tissue oxygenation, coagulation, and decreased inflammatory mediators, "reconstructive surgery" can be applied.

CONCLUSION

Individually adjusted surgical "damage control" and "immune control" are important interactive concepts in polytrauma management.

Magnetic resonance imaging is a useful adjunct in the evaluation of the cervical spine of injured patients

BACKGROUND

Recognition of cervical spine (c-spine) injury is important to minimize the risk of disability. Yet the ideal method to detect injury remains controversial, especially in unexaminable patients. The purpose of this study was to evaluate the incidence of c-spine injury detected by magnetic resonance imaging (MRI) in patients with no abnormalities detected by computerized tomography (CT) scan and to determine whether the treatment plan was altered.

MATERIALS

A retrospective study was performed on all patients who underwent both CT and MRI scanning of the c-spine in 2004 to 2005. Unexaminable patients formed a separate subgroup of the overall cohort. Patients were deemed to be unexaminable by the attending surgeon if their mental status remained depressed after intoxicants were judged to have been metabolized. CT and MRI scan findings were defined as normal if they were without any radiographic abnormality and showed only chronic degenerative changes.

RESULTS

A total of 254 adult patients were included. Of these, 53 patients were unexaminable. Ninety patients showed abnormality on CT scan and were excluded from further analysis. MRI detected an injury in 42 of the remaining 164 patients whose CT scan disclosed nothing abnormal, 27 of which were ligamentous or cord injuries. The findings of the MRI resulted in surgery in 9, maintenance of the rigid cervical collar in 22, and discontinuance of the collar in 11 patients. In the unexaminable cohort, MRI detected an injury in 5 of 46 patients whose CT scan disclosed nothing abnormal, four of which were ligamentous and were treated by cervical collar immobilization.

CONCLUSION

This study supports the practice of obtaining c-spine MRI in patients who are either unexaminable or symptomatic with the CT scan findings normal.

The Swimmer's view: does it really show what it is supposed to show? A retrospective study

BACKGROUND

One of the basic principles in the primary survey of a trauma patient is immobilisation of the cervical spine till cleared of any injury. Lateral cervical spine radiograph is one of the important initial radiographic assessments. More than often additional radiographs like the Swimmer's view are necessary for adequate visualisation of the cervical spine. How good is the Swimmer's view in visualisation of the cervical spine after an inadequate lateral cervical spine radiograph?

METHODS

100 Swimmer's view radiographs randomly selected over a 2 year period in trauma patients were included for the study. All the patients had inadequate lateral cervical spine radiographs. The radiographs were assessed with regards to their adequacy by a single observer. The criteria for adequacy were adequate visualisation of the C7 body, C7/T1 junction and the soft tissue shadow.

RESULTS

Only 55% of the radiographs were adequate. None of the inadequate radiographs provided adequate visualisation of the C7 body and the C7/T1 junction. In 42.2% radiographs the soft tissue shadow was unclear. Poor exposure accounted for 53% of the inadequacies while overlapping bones accounted for the rest.

CONCLUSION

Clearing the cervical spine prior to removing triple immobilisation is essential in a trauma patient. This needs adequate visualisation from C1 to C7/T1 junction. In our study Swimmer's views did not satisfactorily provide adequate visualisation of the cervical spine in trauma patients. We recommend screening the cervical spine by a CT scan when the cervical spine lateral radiographs and Swimmer's views are inadequate.

Controversies in "clearing" trauma to the cervical spine

Clearance of the traumatic cervical spine is a subject affecting most healthcare professionals dealing with trauma patients. There is a host of often contradictory literature making it hard for an interested reader to come to their own informed opinion based on the current evidence. This review aims to outline the relevant literature for the clearance of the traumatic cervical spine with the particular aim of highlighting the contradictions, controversies and unanswered questions still besetting this important subject. A brief, subjective opinion for a combined clinical and imaging protocol for clearance of the traumatic cervical spine is given.

Spinal Trauma

Approximately 30,000 spinal injuries occur in the United States every year. Injuries to the spine and its contents affect predominately young, healthy individuals and are a major cause of disability, with significant socioeconomic consequences. The main cause for spinal injuries is blunt trauma, most commonly caused by motor vehicle accidents, followed by falls and sport injuries. Already, in the initial evaluation of patients who have blunt trauma, multislice CT with two-dimensional (and threedimensional) reformatting is the method of choice. The liberal use of MR imaging is recommended to assess for injuries to soft tissue, the spine and its contents, intervertebral discs, and ligaments.