Radiographic evaluation of cervical spine 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.

Initial radiographic evaluation of the spine after trauma: when, what, where, and how to image the acutely traumatized spine

BACKGROUND

Radiographic evaluation of the spine after an acute traumatic event is an integral part of the initial assessment of the patient. Despite this, an imaging protocol that includes detailed recommendations of the views, modalities, and techniques of radiographic work-up is lacking in the peer-reviewed literature.

STUDY PURPOSE

The goal of the current review was to suggest a uniform protocol for initial imaging in the traumatized patient and provide a rationale and guidelines to assist in deciding which studies are indicated and at what time they are best obtained.

METHODS

The authors' reviewed the available modern, published, English literature, including both peer-reviewed articles and commonly used textbooks, for recommendations concerning which imaging studies are most effective and cost-efficient in detecting spinal injuries in the acute trauma setting. A list of radiologic studies was compiled. A panel of spine surgeon members of the Spine Trauma Study Group, all of whom were highly experienced in trauma management, evaluated the utility and necessity of these imaging studies.

CONCLUSIONS

Surgeons agreed that the mainstay of initial radiographic evaluation of the spine after acute trauma remains plain radiographs. CT scanning remains the best mode of delineating the bony details of a spinal injury and should be used to characterize all bony injuries identified on plain radiographs. As CT technology continues to improve, it is likely to play an even greater role as an initial screening tool. The role for MRI continues to expand, particularly in detecting the soft tissue components of injuries.

Role of oblique radiographs in blunt pediatric cervical spine injury

OBJECTIVE

To determine the usefulness of oblique cervical spine radiography (OCSR) in the management of children who have sustained blunt cervical spine injury, particularly if OCSR is abnormal when no acute abnormalities are shown on standard cervical spine radiography (SCSR).

METHODS

We carried out a blinded radiographic review of 109 patients younger than 16 years evaluated at an academic pediatric trauma center and a community hospital between July 1990 and December 1997. All patients had SCSR (anteroposterior/lateral views) and OCSR performed for a trauma-related event within 7 days of injury.

RESULTS

In 105 patients (96.3%), radiographic impression after review of SCSR and OCSR did not differ from that after SCSR review alone (95% confidence interval 90.9%, 99.0%). Radiographic impression was revised after OCSR review in 4 patients, all with equivocal findings on SCSR, to normal in three patients and abnormal in one patient (subluxation). Of 78 patients without acute abnormalities on SCSR, no patient had acute abnormalities on OCSR (95% CI, 0-3.8%).

CONCLUSIONS

In our series of 109 children who underwent acute radiographic evaluation of blunt cervical spine trauma, oblique views were unlikely to be abnormal if no acute abnormalities were evident on standard anteroposterior and lateral radiographs. Although few patients are likely to benefit from the addition of these views on a routine basis, a useful role for oblique cervical spine radiographs in detecting cervical spine injury in children cannot be excluded based on the results of this study.

Role of flexion-extension radiographs in blunt pediatric cervical spine injury

OBJECTIVE

To determine whether flexion-extension cervical spine radiography (FECSR) is abnormal in children who have sustained blunt cervical spine injury (CSI) when standard cervical spine radiography (SCSR) demonstrates no acute abnormalities.

METHODS

This was a blinded radiographic review of 129 patients < or = 16 years of age evaluated at an academic pediatric trauma center during July 1990-March 1996. All patients had SCSR (anteroposterior/lateral views) and FECSR performed for a trauma-related event within seven days of injury.

RESULTS

Of 46 patients without acute abnormalities on SCSR, one patient (with final clinical diagnosis of "no CSI") had acute abnormalities on FECSR (95% CI = 0.06% to 11.5%). Of 50 patients with isolated loss of lordosis on SCSR, no patient had acute abnormalities on FECSR (95% CI = 0% to 5.8%). The FECSR review revealed no acute abnormalities in 75 of 83 patients (90.4%) with suspicious findings for CSI viewed on SCSR (95% CI = 81.9% to 95.7%). Complications during FECSR were noted in one patient with transient paresthesias (0.8%) (95% CI = 0.02% to 4.2%).

CONCLUSIONS

In children who underwent acute radiographic evaluation of blunt cervical spine trauma, FECSR was unlikely to be abnormal when no acute abnormality or isolated loss of lordosis was evident on SCSR. In a subset of patients with suspicious findings for occult CSI on SCSR, FECSR was useful in ruling out ligamentous instability in the acute, posttrauma setting.

Cervical spine injury in low-impact blunt trauma

Few data are available regarding the incidence of cervical spine injuries following relatively low-impact blunt trauma. This prospective level II trauma center study of low-impact blunt trauma found a 1.30% incidence of cervical spine injury. Impressive differences were found in such parameters as population characteristics, modes of injury, elapsed times to emergency department evaluation, and Revised Trauma Scores between this study group and those reported in prospective level I high-impact blunt trauma series. Cervical spine injury in low-impact blunt trauma is significant and often presents less than dramatically, thus emphasizing a need for maintaining a high index of suspicion at all times.

'Clearance' of cervical spine injury in the obtunded patient

The need to exclude cervical spine injury ('clearance') in an obtunded patient poses a dilemma. The purpose of this study was to find out the current practices for tackling this situation around the country. A questionnaire was sent to all Intensive Care Units who accept injured patients. There is a great diversity in the management and investigation of these patients. There is clearly a need for a recognised protocol for dealing with this difficult situation. Such a protocol is suggested.

'Clearing' cervical spine injuries in polytrauma patients: is it really safe to remove the collar?

Polytrauma patients are at increased risk for occult cervical spine injuries. Those unable to provide clinical clues to injury either remain in hard collars until they are able to cooperate with the physical examination or are deemed "clear of cervical injury" if the emergency room screening radiographs are without obvious bony abnormality. Cervical immobilization for a lengthy period of time is not without morbidity. Missed ligamentous injuries can lead to cervical instability, which in turn can result in permanent neurologic sequelae. This article reviews the current methodologies to "clear the cervical spine" and highlights the inadequacies.

Spinal cord syndromes

In summary, a working knowledge of the spinal cord's anatomy is critical in understanding the various presentations of the spinal cord syndromes. A careful history and physical, including a systematic neurologic examination, will direct the diagnostic work-up. There are a number of disorders that may affect the spine which are slowly progressive and do not necessarily require an emergent evaluation. However, patients with spinal cord trauma and spinal cord metastatic lesions are at risk for rapid and progressive deterioration. These patients require high priorization in care because morbidity and mortality may be significantly impacted by rapid diagnosis and initiation of therapeutic interventions.