Practice Management Guidelines for Identification of Cervical Spine Injuries Following Trauma: Update From the Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee

Cervical spine injury: clinical and medico-legal overview

Spinal trauma is an important cause of disability worldwide. Injury to the cervical spine (CS) occurs frequently after major trauma. 5-10% of patients with blunt trauma have a cervical spine injury. The cervical spine accounts for ~ 50% of all spinal injuries. Determination of CS stability is a common challenge in the acute care setting of patients with trauma. Several issues, indeed, are of particular concern: who needs CS imaging; what imaging should be obtained; when should computed tomography (CT), magnetic resonance imaging (MRI), or flexion/extension (F/E) radiographs be obtained; and how is significant ligamentous injury excluded in the comatose patient. CT and MRI both have roles to play. This article aims to present the different imaging to frame techniques to be used with greater precision in the acute event also for the purpose of planning the next therapeutic process. An overview of the applicability of the same methods in forensic pathology is also provided highlighting possible future biomarker to ease in diagnosis of acute TBI.

A scoping review of cervical spine evaluation in standardised clinical concussion evaluation tools

BACKGROUND

It can be a challenge for clinicians to evaluate trauma that could represent cervical spine injury, concussion, or both. These conditions share common mechanisms of injury and symptom profiles, yet distinct aetiology and management. In the clinical evaluation of concussion, a range of standardised tools are available but the extent to which such tools include cervical spine evaluation is unclear.

OBJECTIVE

To identify a variety of standardised clinical concussion evaluation tools, examine if these tools include cervical spine evaluation, and describe the characteristics of cervical spine evaluation included. To have an informed discussion about how cervical spine evaluation might best be approached after a concussion event.

DESIGN

Scoping review.

METHOD

A structured literature search was performed in eight databases to identify standardised clinical concussion evaluation tools. Each tool was then reviewed for cervical spine evaluation, and the characteristics of tools including cervical spine evaluation were described.

RESULTS

The structured search identified 82 standardised clinical concussion evaluation tools. Eleven tools included cervical spine assessment related primarily to the evaluation of red flags and symptoms, just three included physical examination.

CONCLUSION

Few standardised clinical concussion evaluation tools include cervical spine evaluation, and even fewer include physical examination. Cervical spine evaluation in concussion may benefit from closer alignment with established approaches to screening for clinically significant cervical spine injuries. In concussion, we advocate for an approach to cervical spine evaluation that includes screening for dangerous mechanisms of injury, neurological deficit, distracting injury and neck pain; and physical examination of neck range of motion and neck tenderness.

Outcomes of Patients With Negative Cervical Imaging but Persistent Neck Tenderness Discharged With a Rigid Collar After Trauma

Introduction

It is not uncommon for patients with persistent neck pain after trauma despite negative cervical imaging to be discharged with a rigid collar. Protocols for these patients vary widely. Few studies have evaluated clinical outcomes after discharge. No studies have evaluated the patient’s experience in a cervical collar after discharge.

Methods

We evaluated adults with blunt trauma and negative cervical spine imaging who were discharged in a rigid cervical collar. Over a 19-month period, 45 patients were available for analyses. The primary outcome was any identified missed injuries after discharge. Secondary outcomes were the incidence of patients self-clearing from their collars and complications related to wearing a collar.

Results

There were no missed traumatic injuries on follow-up imaging. Twenty of 45 patients cleared themselves from the collar without a physician order. Twenty-four patients had their collars removed by a provider in the clinic between 1-84 days after injury. One patient removed the collar after being advised by a chiropractor. More than half of patients reported one or more complications from wearing the cervical collar including pain, skin irritation, problems sleeping, difficulty talking or swallowing.

Conclusions

Collar complications are frequent. Follow-up imaging did not change outpatient management. Our data suggests against the practice of discharging trauma patients home in a cervical collar with negative imaging and no focal neurologic deficit.

Magnetic resonance imaging cervical spine in trauma: A retrospective single-centre audit of patient outcomes

OBJECTIVE

Magnetic resonance imaging (MRI) is often used in practice to investigate for cord or discoligamentous injury following blunt trauma and a normal computed tomography (CT). This study investigates the MRI findings and surgical outcomes of patients in this cohort.

METHODS

Retrospective analysis of patients following trauma with suspected cervical spine injury from 2016 to 2019. Inclusion criteria included patients receiving a normal CT of the cervical spine and subsequent MRI due to cervical spine injury symptomatology (persistent tenderness and/or neurology). Inclusion criteria included: age ≥16 years, alert and <72 h from CT to MRI. Mann-Whitney and χ2 statistical analysis techniques were employed.

RESULTS

Two hundred and twenty-eight patients with persistent midline tenderness and/or persistent neurology following blunt trauma and negative CT report were included. One hundred and eighty-one patients received an MRI for persistent tenderness of which 35 revealed abnormal MRI findings. Twenty-one cases required no treatment, 14 cases were treated with a rigid collar with no patients requiring operative management. Forty-seven patients received an MRI for neurological symptoms following blunt trauma and negative CT, with 11 abnormal MRI findings. Management included no treatment (three cases), application of rigid collar (six cases) and operative management (two cases).

CONCLUSION

No alert neurologically intact patient with 'persistent tenderness only' received operative management following a normal CT examination. While MRI is sensitive for detecting soft tissue injuries, the prevalence for detecting clinically significant cervical spine injury in blunt trauma patients in the absence of neurology is low. The utility of MRI in this cohort is questionable considering prolonged spinal immobilisation is not without harm.

Management of patients with cervical spine trauma in the emergency department: a systematic critical appraisal of guidelines with a view to developing standardized strategies for clinical practice

Several guidelines on the evaluation of patients with suspected cervical spine trauma in the Emergency Department (ED) exist. High heterogeneity between different guidelines has been reported. Aim of this study was to find areas of agreement and disagreement between guidelines, to identify topics in which further research is needed and to provide an evidence-based cervical spine trauma algorithm for ED physicians. The three most relevant guidelines published on cervical spine trauma in the last 10 years were selected screening websites of the main scientific societies and through the comparison of a normalized Google Scholar and SCOPUS citation index. We compared the selected guidelines through seven a-priori defined questions. In case of disagreement between the guidelines or if the quality of evidence appeared low, evidence from published systematic reviews on the topic was added to build an evidence-based algorithm for approach to spinal trauma in the ED. The three selected guidelines were: NICE 2016, Eastern Association for the Surgery of Trauma 2009 and American Association of Neurological Surgeons and Congress of Neurological Surgeons 2013. We found complete agreement on one question, partial agreement for one questions, no agreement for two questions, while agreement was not assessable for 3 questions. The agreement between different guidelines and the evidence on which recommendations are based is low. An attempt to build an evidence-based algorithm has been made. More studies are needed on many topics.

Transient Quadriplegia: A Case-Based Approach to Cervical Trauma

INTRODUCTION

Spinal cord injuries are a common reason for presentation to the emergency department (ED). Sports-related spinal injuries are one of the least common spinal injuries, falling behind vehicular accidents, acts of violence, and falls.

CASE REPORT

This case report describes a case of transient quadriplegia in a 17-year-old male who presented to the ED after a helmet-to-helmet collision while participating in football.

CONCLUSION

Emergency physicians should be cognizant of potential spinal cord injury using clinical decision tools and radiologic imaging to properly disposition a patient presenting with cervical spine injury.

Computed tomography-occult discoligamentous instability following blunt cervical spine trauma

Plain CT is routinely ordered following blunt trauma of the cervical spine, and performs well in the exclusion of significant bony injuries. MRI is reserved for cases of suspected neural or posterior ligamentous compromise, and when other imaging modalities are contraindicated. There are patients however, with unremarkable radiology, and without suggestive clinical features, who are later found to have significant discoligamentous instability. In this report, we present two such cases. In both instances, worsening neurological symptoms prompted follow-up imaging, that demonstrated interval development of sub-axial cervical spondylolisthesis, requiring surgery and instrumentation. We identify and discuss radiological features that may be associated with occult discoligamentous injury, and highlight them as avenues for future research. These may prove useful in stratifying at-risk patients for further imaging in the acute setting.

Utilization of computerized tomography and magnetic resonance imaging for diagnosis of traumatic C-Spine injuries at a level 1 trauma center: A retrospective Cohort analysis

Background

Computerized tomography (CT) is a common imaging modality for trauma patients, but there is debate regarding the role of magnetic resonance imaging (MRI) in cervical (C)-spine clearance. We aim to investigate the utilization of CT and MRI imaging in traumatic C-spine clearance and associated outcomes on patients who undergo both imaging modalities.

Methods

A 4-year retrospective review was performed to evaluate the trauma patient imaging algorithm at our institution. The algorithm required CT as a screening examination for traumatic injury patients who are unexaminable because of distracting injury, altered mental status, an abnormal neurological examination, and/or central neck pain. MRI was performed after CT in patients with C-spine injuries identified on CT, those who remained unexaminable, had an abnormal neurological examination, or experienced persistent central neck tenderness. Univariate analyses and adjusted multivariate logistic regression were performed with significance defined as p < 0.05.

Results

805 patients were analyzed. Compared to MRI, CT had a sensitivity of 50.2%, specificity of 76.6%, positive predictive value of 69.7%, and negative predictive value of 59.0% in detecting C-spine injuries. CT and MRI differed significantly in their ability to detect C-spine soft tissue injuries and C1 vertebral fractures (p < 0.05).

Conclusions

MRI is more capable of detecting soft tissue injuries whereas CT is superior in detecting vertebral fractures. Our findings support the need to utilize CT and MRI in conjunction to detect both bony and soft tissue C-spine injuries in traumatically injured patients, who are either unexaminable, have an abnormal neurologic examination, or ongoing central neck tenderness.

[Neurosurgical treatment of cervical spine injuries]

BACKGROUND

Injuries of the cervical spine are quite common with an incidence of more than 3% in trauma patients. The incidence is even higher in elderly patients. Cervical spine injuries might induce severe neurological deficits. Therefore, they must be quickly and adequately diagnosed and treated. Depending on the pattern of injury, conservative or surgical treatment is indicated.

OBJECTIVE

The authors describe the different surgical strategies and treatment options based on the pattern of injury. Typical surgical methods are illustrated by case presentations.

CONCLUSION

Cervical spine injuries should be treated in a trauma centre with extensive expertise in spine surgery. The immobilisation and gentle transportation is important already at the scene of the accident. Nowadays, there are excellent surgical options and strategies available as well as excellent intensive care therapy. These possibilities lead to rapid and good stabilisation of cervical spine injuries and the posttraumatic morbidity and mortality can be reduced significantly especially in elderly patients.

Risk Factors for a False-Negative Examination in Complete Upper Extremity Nerve Lacerations

Background: Many patients with complete nerve lacerations after upper extremity trauma have a documented normal peripheral nerve examination at the time of initial evaluation. The purpose of this study was to determine whether physician-, patient-, and injury-related factors increase the risk of false-negative nerve examinations. Methods: A statewide health information exchange was used to identify complete upper extremity nerve lacerations subsequently confirmed by surgical exploration at 1 pediatric and 2 adult level I trauma centers in a single city from January 2013 to January 2017. Charts were manually reviewed to build a database that included Glasgow Coma Scale score, urine drug screen results, blood alcohol level, presence of concomitant trauma, type of injury, level of injury, laterality, initial provider examination, and initial specialist examination. Bivariate and multivariable analyses were performed to evaluate risk factors for a false-negative examination. Results: Two hundred eighty-eight patients met inclusion criteria. The overall false-negative examination rate was 32.5% at initial encounter, which was higher among emergency medicine physicians compared with extremity subspecialists (P < .001) and among trauma surgeons compared with surgical subspecialists (P = .002). The false-negative rate decreased to 8% at subsequent encounter (P < .001). Risk factors for a false-negative nerve examination included physician specialty, a gunshot wound mechanism of injury, injury at the elbow, and age greater than 71 years. Conclusion: There is a high false-negative rate among upper extremity neurotmesis injuries. Patients with an injury pattern that may lead to nerve injury warrant prompt referral to an upper extremity specialist in an effort to optimize outcomes.

Pediatric cervical spine injury in the United States: Defining the burden of injury, need for operative intervention, and disparities in imaging across trauma centers

BACKGROUND

Pediatric cervical spine injury (PCSI) in children is rare. Incidence of PCSI requiring intervention is not known, and imaging practices for screening in United States trauma centers are not well described.

METHODS

The 2016 NTDB was queried for patients younger than 15 years with PCSI. Incidence of PCSI, operative interventions, and imaging rates were analyzed by age and ACS accreditation status.

RESULTS

Of 84,554 children, 873 (1.03%) had PCSI. Patients <4 years were less likely to have PCSI (0.68% vs. 1.1%, RR 0.59, p < 0.001). 165 children (0.20%) required an intervention for PCSI. 12.8% of all children were screened for PCSI with imaging, 9.3% with CT, and 3.2% with plain X-rays. In spite of similar injury and intervention rates, stand-alone pediatric trauma centers were less likely than others to image patients without PCSI (11% vs. 13% p < 0.001), less likely to utilize CT scan (5.8% vs. 10.6% p < 0.001) and more likely to utilize plain films (5.2% vs. 2.4% p < 0.001).

CONCLUSION

Despite exceedingly low rates of PSCI requiring intervention (0.2%), imaging rates for screening are significant. Stand-alone pediatric trauma centers outperform others in limiting unnecessary imaging.

LEVEL OF EVIDENCE

IV.

Accuracy of craniocervical measurements on CT for identifying partial or complete craniocervical ligament injuries in pediatric patients

PURPOSE

To assess the accuracy of craniocervical measurements for identifying craniocervical injuries and the frequency of subjective findings of craniocervical injuries on CT in pediatric patients.

METHODS

Case-controlled retrospective review of patients ≤ 16 years old with craniocervical junction injuries. Receiver operator curves were created for common craniocervical measurements on CT comparing patients with complete and partial craniocervical injuries to uninjured cohort. Frequency of subjective CT findings of craniocervical injury was assessed in the injured cohort.

RESULTS

For complete disruption injuries (CD) (n = 27), C1-C2 distance (AUC = 0.90, 95%CI = 0.83-0.97), atlanto-occipital distance (AUC = 0.95-0.98, 95%CI = 0.90-1.00), and basion-dens distance (AUC = 0.90, 95%CI = 0.82-0.98) had excellent accuracy diagnosing injury. Powers ratio (AUC = 0.85, 95%CI = 0.76-0.94) had good, basion-posterior axial line (AUC = 0.74, 95%CI = 0.61-0.86) fair, and atlanto-dental distance (AUC = 0.69, 95%CI = 0.57-0.82) poor accuracy. For partial disruption injuries (PD) (n = 21), basion-dens distance (AUC = 0.75, 95%CI = 0.62-0.88) had fair accuracy diagnosing injury. Powers ratio (AUC = 0.63, 95%CI = 0.47-0.79), C1-C2 distance (AUC = 0.60, 95%CI = 0.45-0.75), atlanto-dental distance (AUC = 0.55, 95%CI = 0.39 = 0.71), atlanto-occipital distance (AUC = 0.63-0.65, 95%CI = 0.47-0.81), and basion-posterior axial line (AUC = 0.60, 95%CI = 0.44-0.76) all had poor accuracy. Eighty-one percent (n = 22) of CD and 38% (n = 8) of PD patients had non-concentric atlanto-occipital joints. One hundred percent of CD patients had ≥ 1 soft tissue finding and eighty-one percent (n = 22) had ≥ 2 findings. Seventy-three percent (n = 16) of PD patients had ≥ 1 soft tissue finding. Eighty-six percent (n = 18) of PD patients had non-concentric atlanto-occipital joints and/or soft tissue findings.

CONCLUSION

Craniocervical measurements have poor accuracy for identifying craniocervical injuries in pediatric patients with incomplete craniocervical ligament disruption. Subjective findings of craniocervical injury are frequently present on CT in pediatric patients and can help increase sensitivity for identifying injury.

C-spine clearance in poly-trauma patients: A narrative review

The incidence of cervical spine injury in patients with polytrauma is 3.7%. Early identification and management of cervical spine injuries in these patients play a crucial role in preventing secondary cervical spine and cord injuries. C-spine clearance assumes a pivotal role in reducing the morbidity and mortality associated with cervical spine injury. Despite the availability of various validated management algorithms and protocols for C-spine clearance, there are several controversies regarding C-spine clearance, such as the ideal protocol and imaging modality, clearance of obtunded patients and management of patients that lie out of the described protocols and rules. The current article aims to provide a comprehensive review of the relevant literature and address the prevalent controversies.

Fractures of C2 (Axis) Vertebra: Clinical Presentation and Management

BACKGROUND

Injuries of the upper cervical spine are a major cause of morbidity and mortality due to associated spinal cord and head injuries. The injury patterns of the upper cervical spine are numerous, and the neurologic sequelae are diverse. The axis (C2) is the most commonly fractured vertebra in the upper cervical spine; its unique anatomy and architecture pose difficulties in the diagnosis and the management of its fractures.

METHODS

All cases of acute spinal injuries at Prince Mohammed Bin Abdulaziz Hospital in Riyadh, Saudi Arabia, were screened for fractures of C2 vertebrae. These patients underwent computerized tomography (CT) imaging of the cervical spine with special attention paid to the cranio-cervical junction. Magnetic resonance imaging (MRI) and angiography of the neck were performed to exclude ligamentous tears and vascular injuries. Unstable fractures were fixed surgically. In the remaining cases, a conservative trial was given. All patients were followed up once every 3 months for a period of 1 year. During follow-up, some patients underwent additional CT imaging of the cervical spine to monitor the healing of fractures.

RESULTS

Out of 230 spinal trauma patients, 43.5% suffered from cervical spine injury. C2 fractures were recorded in 26% cases, and fractures of the C2 vertebral body, including pedicles, laminae, lateral masses, and articular processes, were found in many cases, followed by odontoid fractures (50%). No case of atlanto-axial or atlanto-occipital dislocation was recorded. Road traffic accidents were found to be responsible for 92% of cases. The majority of patients were young males, and 96% of patients had no neurological deficit. Only 15% of the patients required surgery for their unstable fractures. Half of the patients attended outpatient follow -up appointments, all of whom underwent CT scanning of the cervical spine 9 months after the accident or operation.

CONCLUSIONS

The axis (C2) is the most commonly affected vertebra in cervical spine trauma, and odontoid fractures make up 50% of all C2 fractures. C2 fractures rarely cause any neurological deficit or vascular injury, and the majority of affected patients can be managed conservatively; only a small proportion requires surgical intervention. Surgical intervention leads to early and complete healing.

The 100 Most-Cited Papers in Traumatic Injury of the Spine

Background

Traumatic injury to the spine can be a complex diagnostic and therapeutic entity often with devastating consequences. Outside of the isolated vertebral column injury costs; annual costs associated with spinal cord injury (SCI) are estimated to exceed $9.7 billion.

Objective

To identify the 100 most-cited articles on spine trauma.

Methods

The Thomson Reuters Web of Science citation indexing service was queried. The articles were sorted by times cited in descending order. Two independent reviewers reviewed the article titles and abstracts to identify the top 100 most-cited articles.

Results

The top 100 articles were found to be cited between 108 (articles #99-100) and 1595 times (article #1). The most-cited basic science article was cited 340 times (#12 on the top 100 list). The oldest article on the top 100 list was from 1953 and most recent from 2012. The number of patients, when applicable, in a study ranged from 9 (article #34) to 34,069 (article #5). Top 100 articles were published in 41 different journals with a wide range of specialities and fields most commonly multidisciplinary. Basic science research encompassed 34 of the 100 articles on the list.

Conclusions

We present the 100 most-cited articles in spinal trauma with emphases on important contributions from both basic science and clinical research across a wide range of authors, specialties, patient populations, and countries. Recognizing some of the most important contributions in the field of spinal trauma may provide insight and guide future work.

Imaging of pediatric cervical spine trauma

While pediatric cervical spine injuries (CSI) are rare, they are associated with high morbidity and mortality and sometimes require expeditious surgical management. In this article, we aim to improve the diagnostic accuracy of pediatric CSI by reviewing normal pediatric cervical anatomy, typical pediatric CSI patterns, and common mimics of pediatric CSI. A literature review was conducted on pediatric CSI, its epidemiology, and the various imaging manifestations and mimics. The most common pediatric CSI occur in the upper cervical spine owing to the higher fulcrum and larger head at a young age, namely prior to age 9 years, while lower CSI occur more frequently in patients older than 9 years. While various craniocervical measurements may be utilized to identify craniocervical disruption, soft tissue injuries may be the only manifestation, thus making pediatric CSI difficult to diagnose on initial imaging. In the acute setting, CT cervical spine is an appropriate initial imaging modality for pediatric CSI evaluation. MRI serves as an additional tool to exclude or identify injuries when initial findings are equivocal. It is essential to recognize the unique anatomy and biomechanics of the pediatric spine and thus discern common pediatric CSI patterns and their mimics.

Evaluation of Cervical Spine Fracture in the Elderly: Can We Trust Our Physical Examination?

The purpose of this trial was to compare National Emergency X-Radiography Utilization Study (NEXUS) criteria (NC) with computed tomography (CT) as the gold standard to evaluate cervical spine (C-spine) fractures in elderly blunt trauma patients. We prospectively compared adult blunt trauma patients 65 years or older (E) with younger than 65 years (NE), evaluating the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of NC compared with CT in these two cohorts. A total of 2785 blunt trauma patients were included of whom 320 were E (average age, 75 years) and 2465 were NE (average age, 36 years). Incidence of C-spine fracture was 12.8 per cent (E) versus 7.4 per cent (NE) ( P = 0.002). Age was an independent predictor of fracture ( P = 0.01). NC had a sensitivity of 65.9 per cent in E and PPV of 19.3 per cent in E ( P = 0.001) versus a sensitivity of 84.2 per cent in NE and PPV of 10.6 per cent ( P < 0.0001). The specificity was 59.5 per cent for E versus 42.6 per cent for NE (NPV, 92.2% E vs 97.1% NE). This study suggests that NEXUS criteria are not an appropriate assessment tool when applied to severe blunt trauma patients, particularly in the elderly population who had more missed injures than their younger counterparts. CTshould be used in all blunt trauma patients regardless of whether they meet NEXUS criteria.

Prevertebral Soft-Tissue Swelling at C7 Is Highly Sensitive for Cervical Spine Ligamentous Injury Study Type: Retrospective Cohort Study

To determine the diagnostic potential of prevertebral soft-tissue (PVST) swelling in cervical spine ligamentous injury (LI).

Cervical spine clearance after blunt trauma: current state of the art

No definite consensus exists for the clearance of the cervical spine (C-spine) after blunt trauma, despite many validated algorithms, recommendations and guidelines. We intend to answer the most relevant questions with which physicians are confronted when clearing C-spines after blunt trauma in emergency departments (EDs). To exclude significant C-spine injuries we designed an algorithm to be compatible with clinical practice, to simplify patient management and avoid unrewarding evaluation.

We conducted an exploratory PubMed search including articles published from January 2000 to October 2018. Keywords used were “cervical spine”, “injury”, “clearance”, “Canadian C-spine Rule”, “CCR” and “national emergency x-radiography utilization study”. Clinical and experimental studies were included in a detailed review.

We based our literature review on 33 articles. While answering fundamental triage questions from daily clinical practice, the current literature is discussed in detail. We designed an algorithm for the C-spine clearance suitable for any trauma centre with a high-quality multiplanar reconstruction computerized tomography (CT) scan continuously available.

The high sensitivity of the Canadian C-spine Rule (CCR) prevents missing C-spine injuries while limiting the amount of unnecessary radiologic examinations. Plain radiographs were fully abandoned for C-spine clearance. A negative CT scan is sufficient to clear the majority of C-spine injuries and allows for collar removal. In case of motor symptoms or radio-clinical discrepancy, the advice of a specialized spine surgeon must be requested. Magnetic resonance imaging must not be routinely used. Neck pain despite negative imaging is not a reason to delay removal of stiff cervical collars.

Cite this article: EFORT Open Rev 2020;5:253-259. DOI: 10.1302/2058-5241.5.190047

Prolonged use of spinal precautions is associated with increased morbidity in the trauma patient

BACKGROUND

Patients who experience traumatic spine injuries remain in spinal precautions (SP) to minimize the risk of devastating cord injury while awaiting definitive management. This study examines the incidence of pneumonia (PNA), urinary tract infection (UTI), deep vein thrombosis (DVT), or pulmonary embolism (PE) in this population.

STUDY DESIGN

From 2014 to 2016, 344 patients aged 18 and older with spinal column injuries were identified in a prospectively-collected registry at an urban, level 1 trauma center. After exclusion criteria, 330 patients were reviewed and the following were analyzed: demographics, duration of SP, time to intervention, and rates of PNA, UTI, and DVT or PE. Those patients kept in SP for ≤ 72 h ("prolonged") were compared to patients maintained in SP for > 72 h ("early").

RESULTS

Mean age was 54.6 years (SD, 21.7), median Injury Severity Score (ISS) 10 (IQR, 5-17). The median SP was 4.0 (IQR, 3.0-6.0) days. Fifty-eight (17.6%) patients underwent fixation and 170 (51.5%) received a brace. 102 (30.9%) patients initially awaiting a brace were cleared after MRI. 93 (28.2) patients suffered one of the tracked complications; 51 (15.5%) developed PNA, 35 (10.6%) UTI, 23 (7.0%) DVT, and 5 (1.5%) PE. Rate of overall complications between patients with SP ≤ 72 h versus patients with SP > 72 h was statistically significant (20.5% vs 34.6%, p = 0.005) as was the incidence of UTI (14.5 vs 6.0, p = 0.012).

CONCLUSION

Prolonged SP (>72 h) is associated with increased rates of immobility-associated morbidities. Focus should be on prompt, definitive care and early mobilization.

LEVEL OF EVIDENCE

III Retrospective review of prospectively-collected data.

Current Topics in the Management of Acute Traumatic Spinal Cord Injury

Acute traumatic spinal cord injury (SCI) affects more than 250,000 people in the USA, with approximately 17,000 new cases each year. It continues to be one of the most significant causes of trauma-related morbidity and mortality. Despite the introduction of primary injury prevention education and vehicle safety devices, such as airbags and passive restraint systems, traumatic SCI continues to have a substantial impact on the healthcare system. Over the last three decades, there have been considerable advancements in the management of patients with traumatic SCI. The advent of spinal instrumentation has improved the surgical treatment of spinal fractures and the ability to manage SCI patients with spinal mechanical instability. There has been a concomitant improvement in the nonsurgical care of these patients with particular focus on care delivered in the pre-hospital, emergency room, and intensive care unit (ICU) settings. This article represents an overview of the critical aspects of contemporary traumatic SCI care and notes areas where further research inquiries are needed. We review the pre-hospital management of a patient with an acute SCI, including triage, immobilization, and transportation. Upon arrival to the definitive treatment facility, we review initial evaluation and management steps, including initial neurological assessment, radiographic assessment, cervical collar clearance protocols, and closed reduction of cervical fracture/dislocation injuries. Finally, we review ICU issues including airway, hemodynamic, and pharmacological management, as well as future directions of care.

Prevalence of Fractures and Diagnostic Accuracy of Emergency X-ray in Older Adults Sustaining a Low-Energy Fall: A Retrospective Study

BACKGROUND

Plain radiography (XR) series are standard of care for detection of fall-related fractures in older patients with low-energy falls (LEF) in the emergency department (ED). We have investigated the prevalence of fractures and diagnostic accuracy of XR imaging in the ED.

METHODS

2839 patients with LEF, who were presented to two urban level I trauma centers in 2016 and received XR and computed tomography (CT), were consecutively included in this retrospective cohort study. The primary endpoint was the prevalence of fractures of the vertebral column, rib cage, pelvic ring, and proximal long bones. Secondary endpoints were diagnostic accuracy of XR for fracture detection with CT as reference standard and cumulative radiation doses applied.

RESULTS

Median age was 82 years (range 65-105) with 64.1% female patients. Results revealed that 585/2839 (20.6%) patients sustained fractures and 452/2839 (15.9%) patients received subsequent XR and CT examinations of single body regions. Cross-tabulation analysis revealed sensitivity of XR of 49.7%, a positive likelihood ratio of 27.6, and negative likelihood ratio of 0.5.

CONCLUSIONS

XR is of moderate diagnostic accuracy for ruling-out fractures of the spine, pelvic ring, and rib cage in older patients with LEF. Prospective validations are required to investigate the overall risk-benefit of direct CT imaging strategies, considering the trade-off between diagnostic safety, health care costs, and radiation exposure.

Evaluation of clinical criteria to determine the need for cervical spine imaging in victims of blunt assault

The purpose of this study is to evaluate effectiveness of clinical criteria, specifically the NEXUS Criteria, in determining the need for cervical spine imaging in victims of blunt assault to head and face. CT results from victims of blunt assault to the head and face were compared with presenting clinical findings. The presence or absence of cervical spine injury was correlated with positive NEXUS criteria to determine if the clinical criteria appropriately risk stratified patients in this population. Incidence of c-spine injury was 1.09% (7/641). For clinically significant injury, the incidence dropped to 0.16% (1/641). PPV of NEXUS criteria in blunt assault to the head and face for any injury in our study was 1.4% (95% CI: 0.6%-2.6%) compared to 2.7% (95% CI: 2.6%-2.8%) in the NEXUS validity study. PPV of NEXUS criteria in blunt assault to the head and face for significant injury in our study was 0.2% (95% CI: 0%-0.9%) compared to 1.9% (95% CI: 1.8%-2.0%) in the NEXUS validity study. The findings demonstrate a statistically significant difference between the PPV of NEXUS criteria in victims of blunt assault to the head and face when compared to all blunt trauma in the NEXUS validity study. This suggests that the clinical criteria do not adequately stratify this low risk population, leading to imaging over-utilization. Limited use of cervical spine imaging in victims of blunt assault will decrease radiation exposure and healthcare costs and will strengthen the validity of clinical risk stratification for more high-risk groups.

Variation in the use of MRI for cervical spine clearance: an opportunity to simultaneously improve clinical care and decrease cost

Background

For years, controversy has existed about the ideal approach for cervical spine clearance in obtunded, blunt trauma patients. However, recent national guidelines suggest that MRI is not necessary for collar clearance in these patients. The purpose of this study was to identify the extent of national variation in the use of MRI and assess patient-specific and hospital-specific factors associated with the practice.

Methods

We performed a retrospective review of the National Trauma Data Bank from 2007 to 2012. We included blunt trauma patients aged ≥18 years, admitted to level 1 or 2 trauma centers (TCs), with a Glasgow Coma Scale <8, Abbreviated Injury Scale >3 for the head and mechanically ventilated for more than 72 hours. Multilevel modeling was used to identify patient-level and hospital-level factors associated with spine MRI use.

Results

32 125 obtunded, blunt trauma patients treated at 395 unique TCs met our inclusion criteria. The mean proportion of patients who received MRI over the entire sample was 9.9%. The proportions of patients at each hospital who received a spine MRI ranged from 0.5% to 68.7%. Younger patients, with injuries from motor vehicle collisions and pedestrian injuries, were more likely to receive MRI. When controlling for other variables, Injury Severity Score (ISS) was not associated with MRI use. Hospitals in the Northeast, level 1 TCs and non-teaching hospitals were more likely to obtain MRIs in this patient population.

Conclusion

After controlling for patient-level characteristics, variation remained in MRI use based on geography, trauma center level and teaching status. This evidence suggests that current national guidelines limiting the use of MRI for cervical spine evaluation following blunt trauma are not being followed consistently. This may be due to physicians not being up to date with best practice care, unavailability of locally adopted protocols in institutions or lack of consensus among clinical providers.

Level of evidence

Prognostic and epidemiological, level III.

Evaluating the cervical spine in confused or unconscious adults after blunt trauma

Potential injury to the cervical spine should be considered in all patients who have suffered blunt trauma. Early spinal immobilization is required to minimize the risk of secondary spinal cord injury. However, prolonged immobilization is associated with its own morbidity. Clinical evaluation of the cervical spine in confused or unconscious adult trauma patients is challenging, and imaging is required to safely 'clear' the cervical spine. Despite the existence of national guidelines, significant variations in practice exist. This article summarizes the evidence for the initial stabilization of the cervical spine in adult trauma patients. It reviews the imaging modalities available and the criteria for discontinuation of cervical spine immobilization.

Radiology: Imaging Trauma Patients in a Deployed Setting

Medical imaging plays a critical role in the rapid diagnosis, effective triage, and management of complex poly-trauma patients. High-quality medical imaging can be accomplished successfully in a deployed or wartime setting. Due to advances in aggressive resuscitation techniques and the speed of the latest generation computed tomography scanners (64-detector and beyond), rapid trauma scans utilizing computed tomography and ultrasound imaging can routinely be performed prior to taking the patient to the operating room potentially providing the trauma team with lifesaving information. This clinical practice guideline provides an overview of the imaging modalities available in austere settings, the equipment required, and the role that each plays in triaging and diagnosis of the acutely injured poly-trauma patients.

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.

Enhancing Evaluation of Cervical Spine: Thresholds for Normal CT Relationships in the Subaxial Cervical Spine

Background

Very little normative computed tomography (CT) scan data exist defining expected relationships of vertebral structures in the intact cervical spine. Better understanding of normal relationships should improve sensitivity of injury detection, particularly for facet subluxation. The purpose of this paper was to describe the normal anatomical relationships and most sensitive measurements to detect abnormal alignment in the subaxial cervical spine.

Methods

A group of 30 CT scans with no documented cervical spine injury were utilized from an established database in a trauma population. Twenty-two anatomical measurements were made for each level of the subaxial cervical spine using Microview software. For the purposes of measurement, the upper confidence limit of normal was reported as two standard deviations from the mean.

Results

The novel, CT based measurements of bone articulation were generally smaller and had lower confidence intervals compared to traditional radiographic measurements of midline structures (such as interspinous distance, interlaminar widening, disc space widening). The upper limit of normal of facet joint height was reported (1.54 mm anterior, 1.27 mm posterior, and 2.0 mm midportion), which may help identify distractive-flexion injuries. The upper limit of normal vertebral translation (2.0 mm) was also reported to identify translation/rotation injuries.

Conclusions

Normal CT measurements for the subaxial cervical spine, especially in the facets, were found to have small confidence limits and variation. Based upon these findings, we conclude that facet measurements and translation may be better screening tools than traditional radiographic criteria based upon midline structures. Using these measurements may improve detection of cervical spine injuries warranting further imaging or investigation and reducing missed injuries.

Clinical Relevance

Improved understanding of normal anatomic measures in the subaxial spine will allow for better screening and identification of injuries.

Delay in clearing cervical spine injuries in obtunded trauma patients and its implications

Introduction

Prompt recognition of cervical spine injuries may limit spinal cord damage. This prospective audit assessed the time needed to formally confirm the status of cervical spine using a computed tomography scan, the reasons for any delays, and the subsequent outcomes.

Methodology

Prospective audit analysed the data of 100 consecutive unconscious trauma patients, admitted over a seven-month period, to ascertain whether there was a ‘weekend’ effect in validating the cervical spine status radiologically, and whether the delays were associated with an increased risk of pneumonia and other complications. The sensitivity and specificity of using bony fractures and mal-alignment on the computed tomography scans to diagnose cervical spine injuries were calculated.

Results

Significant radiological evidence of cervical spine injuries occurred in 37 patients (37%). A delay in >48 h to ascertain the cervical spine status occurred in 36 patients, mostly due to logistical (58%) reasons, and this was associated with an increased risk of pneumonia requiring antibiotics (p < 0.001). A ‘weekend’ effect and presence of cervical spine injuries were not significantly related to the time to confirm the cervical spine injury status radiologically. The specificity (98%) of using bony fractures and mal-alignment on the computed tomography to diagnose cervical spine injuries was high, but its sensitivity (83.8%) was only modest.

Conclusions

A delay to confirm the cervical spine injury status was common and associated with an increased risk of pneumonia in unconscious trauma patients, particularly among those who did not sustain any cervical spine injuries. The low sensitivity of computed tomography to exclude non-bony cervical spine injuries suggests that selective early use of magnetic resonance imaging scans for high-risk unconscious trauma patients may improve patient outcomes.

Review article: Best practice management of neck pain in the emergency department (part 6 of the musculoskeletal injuries rapid review series)

Neck pain and whiplash injuries are a common presentation to the ED, and a frequent cause of disability globally. This rapid review investigated best practice for the assessment and management of musculoskeletal neck pain in the ED. PubMed, CINAHL, EMBASE, TRIP and the grey literature, including relevant organisational websites, were searched in 2017. Primary studies, systematic reviews and guidelines were considered for inclusion. English-language articles published in the past 12 years addressing acute neck pain assessment, management or prognosis in the ED were included. Data extraction was conducted, followed by quality appraisal to rate levels of evidence where possible. The search revealed 2080 articles, of which 51 were included (n = 22 primary articles, n = 13 systematic reviews and n = 16 guidelines). Consistent evidence was found to support the use of 'red flags' to screen for serious pathologies, judicious use of imaging through clinical decision rule application and promotion of functional exercise coupled with advice and reassurance. Clinicians may also consider applying risk-stratification methods, such as using a clinical prediction rule, to guide patient discharge and referral plans; however, the evidence is still emerging in this population. This rapid review provides clinicians managing neck pain in the ED a summary of the best available evidence to enhance quality of care and optimise patient outcomes.

Risk Factors for Cervical Spine Injury in Patients With Mandibular Fractures

PURPOSE

Patients with mandibular fractures are known to be at risk of concomitant cervical spine injuries (CSIs). The purpose of this study was to determine the incidence of and risk factors for CSIs in these patients.

PATIENTS AND METHODS

We conducted a retrospective cohort study of adult trauma patients with mandibular fractures from June 1, 2007, through June 30, 2017. Patients were identified through the Massachusetts General Hospital trauma registry and were included as study patients if they had a mandibular fracture and computed tomography or magnetic resonance imaging of the cervical spine. The primary predictor variable was the site of the mandibular fracture; the primary outcome variables were the presence of CSIs and death. The other variables were demographic characteristics (age, gender, alcohol use, and drug use), Injury Severity Score, Glasgow Coma Scale, presence of midface and extra-craniofacial injuries, and etiology. Data analysis consisted of univariate correlations and construction of a multivariate model to determine independent risk factors for CSIs.

RESULTS

Of 23,394 patients in the trauma registry, 3,950 (17%) had craniomaxillofacial fractures and 1,822 (7.7%) had CSIs. The frequency of CSIs in the overall cohort of mandibular fracture patients (n = 1,147) was 4.4%, and for admitted patients (n = 495), it was 10%. The mean age of patients with mandibular fractures plus CSIs was 40 years (range, 19 to 93 years); 84% were men. Patients with a ramus-condyle unit fracture, mandibular fracture plus any midface fracture, non-craniomaxillofacial injury, and motor vehicle crash etiology had the highest frequency of CSIs. Ramus-condyle unit fractures and chest injuries were independent risk factors for CSIs in the multivariate model (P = .0334 and P = .0013, respectively). The mortality rate was 4-fold higher in patients with CSIs versus those without CSIs.

CONCLUSIONS

The presence of ramus-condyle unit fractures and the presence of chest injuries were independent risk factors for CSIs. Oral and maxillofacial surgeons should be diligent in ruling out CSIs in mandibular fracture patients.

Development of a new clinical decision rule for cervical CT to detect cervical spine injury in patients with head or neck trauma

Objective

Previous cervical spine imaging decision rules have been based on positive findings on plain X-ray and are limited by lack of specificity, age restrictions and complicated algorithms. We previously derived and validated a clinical decision rule (Rule 1) for detecting cervical spine injury (CSI) on CT in a single-centre study. This recommended CT for patients with (1) GCS score <14, (2) GCS 14–15 and posterior cervical tenderness or neurological deficit, (3) age ≥60 years and fall down stairs, or (4) age <60 and injured in a motorcycle collision or fallen from height. This study assessed the accuracy and reliability of this rule and refined the rule.

Methods

We conducted a prospective, dual-centre study at two Japanese EDs between August 2012 and March 2014. Patients with head or neck injury ≥16 years of age were included. Clinical data were collected from medical records. Imaging was at the discretion of the treating physician. CSI was diagnosed as a fracture or dislocation seen on CT; patients who were not imaged were followed for 14 days. We analysed the sensitivity and specificity of Rule 1 and refined it post hoc using recursive partitioning.

Results

1192 patients were enrolled. 927 completed follow-up. Of these, 584 (63.0%) underwent CT imaging and 38 had CSI. Sensitivity and specificity of Rule 1 were 92.1% (95% CI 79.2% to 97.3%) and 58.6% (95% CI 55.4% to 61.9%). A second rule (Rule 2) was derived recommending CT for those with any of the following: GCS <14, cervical tenderness, neurological deficit or mechanism of injury (fall down stairs, motorcycle collision or fall from height) without age limits. Sensitivity and specificity were 100% (95% CI 90.8% to 100%) and 51.9% (95% CI 48.6% to 55.2%), respectively.

Conclusions

Our initial CT decision rule had lower sensitivity than in our initial validation study. A refined decision rule based on GCS, neck tenderness, neurological deficit and mechanism of injury showed excellent sensitivity with a small loss of specificity. Rule 2 will now need validation in an independent cohort.

Reporting of CT cervical spine after office hours by radiology trainees-analysis of discrepancy rates and RADPEER scores

PURPOSE

To review the errors made by radiology trainees in the reporting of cervical spine CTs (CCT) and to compare the discrepancy rates between the stages of training.

METHODS

All CCTs reported by trainees after office hours between January 2015 and December 2015 were retrospectively reviewed by a team of five musculoskeletal consultants with experience ranging between 7 and 15 years. Discrepancies between the provisional report by the trainee and the findings by the musculoskeletal consultants were graded according to the RADPEER scoring system. Sensitivity and specificity of the trainees were assessed.

RESULTS

Of 254 CCT provisional reports, there were 12 (4.7%) discrepancies, of which 5 (2.0%) discrepancies were likely to be clinically significant. We found a clinically significant difference between the stage of training of the trainee and RADPEER score (P = 0.023). The sensitivity and specificity of the senior radiology trainees were 97.0 and 98.1%, respectively, and that of the junior radiology trainees were 80 and 98.0% respectively (P = 0.039). Conditions misinterpreted as fractures include degenerative changes (n = 2) and nutrient vessel (n = 1). Other missed abnormalities include ossification of the posterior longitudinal ligament (n = 1), fracture of the foramen transversarium (n = 2), vertebral body fractures (n = 2), articular facet fractures (n = 2), and transverse process fractures (n = 2).

CONCLUSION

Cervical spine CTs performed after office hours can be safely interpreted by senior radiology trainees to a reasonable degree, although a targeted intervention to improve diagnostic performance of junior radiology trainees may be of clinical benefit.

Enhancing evaluation of cervical spine: Thresholds for normal CT relationships in the subaxial cervical spine

Background

Very little normative CT scan data exist defining expected relationships of vertebral structures in the intact cervical spine. Better understanding of normal relationships should improve sensitivity of injury detection, particularly for facet subluxation. The purpose of this paper was to describe the normal anatomical relationships and most sensitive measurements to detect abnormal alignment in the subaxial cervical spine.

Methods

A group of 30 CT scans with no documented cervical spine injury were utilized from an established data base in a trauma population. Twenty-two anatomical measurements were made for each level of the subaxial cervical spine using Microview software. For the purposes of measurement, the upper confidence limit of normal was reported as two standard deviations from the mean.

Results

The novel, CT based measurements of bone articulation were generally smaller and had lower confidence intervals compared to traditional radiographic measurements of midline structures (such as interspinous distance, interlaminar widening, disc space widening). The upper limit of normal of facet joint height was reported (1.54mm anterior, 1.27mm posterior, and 2.0mm midportion) which may help identify distractive-flexion injuries. The upper limit of normal vertebral translation (2.0mm) was also reported to identify translation/rotation injuries.

Conclusions

Normal CT measurements for the subaxial cervical spine, especially in the facets, were found to have small confidence limits and variation. Based upon these findings, we conclude that facet measurements and translation may be better screening tools than traditional radiographic criteria based upon midline structures. Using these measurements may improve detection of cervical spine injuries warranting further imaging or investigation and reducing missed injuries.

Clinical Relevance

Improved understanding of normal anatomic measures in the subaxial spine will allow for better screening and identification of injuries.

Ethical Statement

This was approved by the Office of Research Institutional Review Board, Baylor College of Medicine.

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.

X-ray vs. CT in identifying significant C-spine injuries in the pediatric population

PURPOSE

Evaluation of cervical spine injury (CSI) in children requires rapid, yet accurate assessment of damage. Given concerns of radiation exposure, expert consensus advises that computed tomography (CT) should be used sparingly. However, CT can provide superior image resolution and detection of pathology. Herein, we evaluate if X-ray offers equal diagnostic accuracy compared to CT imaging in identifying CSI in children.

METHODS

We conducted a retrospective study between October 2000 and March 2012 of pediatric patients evaluated for cervical spine injury at a level 1 trauma center. All patients included in this study were imaged with cervical spine X-rays and CT at the time of injury. Demographic information, mechanism of injury, significant versus non-significant injury (as defined by the NEXUS criteria), radiographic findings, level of the injury, presence of spinal cord injury, treatment, clinical outcome, and length of follow-up were collected. Chi-squared (χ ²) and Fisher's exact tests were used as appropriate and means and standard deviations were reported.

RESULTS

We identified 1296 patients who were screened for CSI. Of those, 164 patients were diagnosed with spinal cord/column injuries (CSI). Eighty-nine patients were excluded for only having a CT or X-ray imaging without the other modality. Thus, a total of 75 patients with CSI were included in the final cohort. Using the NEXUS definitions, 78% of patients had clinically significant injuries while 22% had non-significant injuries. There were no injuries detected on X-ray that were not also detected on CT. For all injuries, X-ray sensitivity was 50.7%. X-rays were more sensitive to significant injuries (62.3%) compared in non-significant injuries, which were missed on all X-rays (0%). Therefore, X-rays did not identify 24 significant cervical spine injuries (32%) as defined by NEXUS.

CONCLUSIONS

CT is superior to X-rays in detecting both clinically significant and insignificant cervical spine injuries. These results were not dependent on patient age or location of the injury. We recommend CT imaging in the evaluation of suspected cervical spine injuries in children.

LEVEL OF EVIDENCE

III.