1
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Abbasi AB, Cifu AS. Why some Patients Benefit from Participating in a Sham Surgery Trial. Ann Surg 2024; 279:577-582. [PMID: 37870249 DOI: 10.1097/sla.0000000000006141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
OBJECTIVE We analyze the ethics of sham surgical trials from a utilitarian perspective and explore whether patients can benefit from participating in these trials. BACKGROUND Sham-controlled randomized trials are an essential tool to evaluate the risks and benefits of some surgical procedures. However, sham trials are controversial because they expose patients to the harms of a sham procedure without the possibility of benefit. We argue that ethical analyses of sham trials have focused only on the harms of sham surgery and neglected to account for the harms of the procedure being studied. METHODS We develop a theoretical model to estimate the harms and benefits experienced by patients who enter a sham surgery trial, taking into account the harms and benefits of the sham and intervention. RESULTS When the procedure in question is found to be ineffective, sham trials typically result in a net benefit to participants because some participants are only exposed to the harms of the sham procedure, which are much lower than the harms of the full procedure. When the procedure is found to be beneficial, the primary harm to patients who underwent the sham is not due to the sham itself but because they suffer a delay in receiving an effective intervention. CONCLUSIONS Patients often benefit from participating in sham surgery trials because the harms of the sham procedure are lower than the harms of the full procedure, which may turn out to be ineffective. Our results call for re-thinking the ethics of sham surgery trials.
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Affiliation(s)
- Ali B Abbasi
- Department of Surgery, University of California at San Francisco, San Francisco, CA
| | - Adam S Cifu
- Department of Medicine, The University of Chicago, San Francisco, CA
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2
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Docking S, Gao L, Ademi Z, Bonello C, Buchbinder R. Use of Decision-Analytic Modelling to Assess the Cost-Effectiveness of Diagnostic Imaging of the Spine, Shoulder, and Knee: A Scoping Review. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:467-475. [PMID: 36940059 PMCID: PMC10119214 DOI: 10.1007/s40258-023-00799-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/23/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Limited evidence is available on the cost-effectiveness of diagnostic imaging for back, neck, knee, and shoulder complaints. Decision analytic modelling may be an appropriate method to synthesise evidence from multiple sources, and overcomes issues with trial-based economic evaluations. OBJECTIVE The aim was to describe the reporting of methods and objectives utilised in existing decision analytic modelling studies that assess the cost-effectiveness of diagnostic imaging for back, neck, knee, and shoulder complaints. METHODS Decision analytic modelling studies investigating the use of any imaging modality for people of any age with back, neck, knee, or shoulder complaints were included. No restrictions on comparators were applied, and included studies were required to estimate both costs and benefits. A systematic search (5 January 2023) of four databases was conducted with no date limits imposed. Methodological and knowledge gaps were identified through a narrative summary. RESULTS Eighteen studies were included. Methodological issues were identified relating to the poor reporting of methods, and measures of effectiveness did not incorporate changes in quantity and/or quality of life (cost-utility analysis in only ten of 18 studies). Included studies, particularly those investigating back or neck complaints, focused on conditions that were of low prevalence but have a serious impact on health (i.e. cervical spine trauma, cancer-related back pain). CONCLUSIONS Future models should pay particular attention to the identified methodological and knowledge gaps. Investment in the health technology assessment of these commonly utilised diagnostic imaging services is needed to justify the current level of utilisation and ensure that these services represent value for money.
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Affiliation(s)
- Sean Docking
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Lan Gao
- Deakin Health Economics, Institute for Health Transformation, School of Health & Social Development, Deakin University, Geelong, VIC, Australia
| | - Zanfina Ademi
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Centre for Medicine Use and Safety, Monash University, Parkville, VIC, Australia
| | - Christian Bonello
- La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, VIC, Australia
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Teuber H, Halvachizadeh S, Muthirakalayil M, Yin L, Eisenkrein H, Hildebrand F, Kobbe P, Sprengel K, Mica L, Alkadhi H, Pape HC, Pfeifer R. Can radiologic parameters used to detect cervical spinal instability be used in patients with ankylosing spondylitis? Eur J Med Res 2023; 28:97. [PMID: 36841781 PMCID: PMC9960164 DOI: 10.1186/s40001-023-01052-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 02/07/2023] [Indexed: 02/27/2023] Open
Abstract
INTRODUCTION Cervical spinal instability can be difficult to detect in the shock room setting even with the utilization of computed tomography (CT) scans. This may be especially true in patients with cervical degenerative disease, such as ankylosing spondylitis (AS). The purpose of this study was to investigate the influence AS has on various radiologic parameters used to detect traumatic and degenerative instability of the cervical spine, to assess if CT imaging in the shock room is diagnostically appropriate in this patient population. METHODS A matched, case-control retrospective analysis of patients with AS and controls without AS admitted at two level-1 trauma centers was performed. All patients were admitted via shock room and received a polytrauma CT. Twenty-four CT parameters of atlanto-occipital dislocation/instability, traumatic and degenerative spondylolisthesis, basilar invagination, and prevertebral soft tissue swelling were assessed. Since the study was assessing normal values, study patients were included if they had no injury to the cervical spine. Study patients were matched by age and sex. RESULTS A total of 78 patients were included (AS group, n = 39; control group, n = 39). The evaluated cervical radiologic parameters were largely within normal limits and showed no significant clinical or morphologic differences between the two groups. CONCLUSION In this analysis, CT measurements pertaining to various cervical pathologies were not different between patients with and without AS. Parameters to assess for atlanto-occipital dislocation/instability, spondylolisthesis, or basilar invagination in the trauma setting may reliably be used in patients with AS.
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Affiliation(s)
- Henrik Teuber
- Department of Trauma Surgery and Harald-Tscherne Laboratory, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
| | - Sascha Halvachizadeh
- grid.7400.30000 0004 1937 0650Department of Trauma Surgery and Harald-Tscherne Laboratory, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Melvin Muthirakalayil
- grid.7400.30000 0004 1937 0650Department of Trauma Surgery and Harald-Tscherne Laboratory, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Luxu Yin
- grid.1957.a0000 0001 0728 696XDepartment of Orthopedics Trauma Surgery, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Harry Eisenkrein
- grid.1957.a0000 0001 0728 696XDepartment of Orthopedics Trauma Surgery, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Frank Hildebrand
- grid.1957.a0000 0001 0728 696XDepartment of Orthopedics Trauma Surgery, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Philipp Kobbe
- grid.1957.a0000 0001 0728 696XDepartment of Orthopedics Trauma Surgery, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Kai Sprengel
- grid.7400.30000 0004 1937 0650Department of Trauma Surgery and Harald-Tscherne Laboratory, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Ladislav Mica
- grid.7400.30000 0004 1937 0650Department of Trauma Surgery and Harald-Tscherne Laboratory, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Hatem Alkadhi
- grid.7400.30000 0004 1937 0650Department of Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Hans-Christoph Pape
- grid.7400.30000 0004 1937 0650Department of Trauma Surgery and Harald-Tscherne Laboratory, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Roman Pfeifer
- grid.7400.30000 0004 1937 0650Department of Trauma Surgery and Harald-Tscherne Laboratory, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Daggett SM, Cantarelli T, Gyftopoulos S, Krueger P, Ross AB. Cost-effectiveness Analysis in Diagnostic Musculoskeletal Radiology: A Systematic Review. Curr Probl Diagn Radiol 2022; 52:20-24. [DOI: 10.1067/j.cpradiol.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 07/27/2022] [Indexed: 11/22/2022]
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Okereke I, Mmerem K, Balasubramanian D. The Management of Cervical Spine Injuries - A Literature Review. Orthop Res Rev 2021; 13:151-162. [PMID: 34611449 PMCID: PMC8487293 DOI: 10.2147/orr.s324622] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 08/13/2021] [Indexed: 12/01/2022] Open
Abstract
Due to the inherent bony instability of the cervical spine, there is an over-reliance on ligamentous structures for stability, making this segment of the vertebral column most prone to traumatic injuries. The frequently occurring mechanisms of injury include axial compression, hyper-flexion, hyper-extension, and rotational type injuries. Good pre-hospital care and a thorough assessment in the emergency department of patients suspected to have a cervical spine injury (CSI) leads to improved clinical outcomes. The objective of the initial evaluation of a patient with a suspected CSI is to identify the presence of injuries through thorough clinical and radiologic assessments as missed injuries are potentially catastrophic. The treatment of cervical spine injuries can be conservative, pharmacological, or surgical, and aims to halt SCI progression, stabilize the spine, and to allow rehabilitation of the patient.
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Affiliation(s)
- Isaac Okereke
- Department of Trauma & Orthopaedics, The Royal London Hospital, London, UK
| | - Kingsley Mmerem
- Department of Trauma & Orthopaedics, The Royal London Hospital, London, UK
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Booz C, Yel I, Martin SS, Lenga L, Eichler K, Wichmann JL, Vogl TJ, Albrecht MH. Incremental Diagnostic Value of Virtual Noncalcium Dual-Energy Computed Tomography for the Depiction of Cervical Disk Herniation Compared With Standard Gray-Scale Computed Tomography. Invest Radiol 2021; 56:207-214. [PMID: 33109918 DOI: 10.1097/rli.0000000000000734] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to investigative the diagnostic accuracy of colored dual-energy computed tomography (CT) virtual noncalcium (VNCa) series for analyzing cervical disk herniation compared with standard gray-scale CT images, with magnetic resonance imaging (MRI) serving as standard of reference. MATERIALS AND METHODS Data from 57 patients who underwent noncontrast dual-source CT and 3.0-Tesla (T) MRI within 2 weeks between January 2017 and December 2018 were retrospectively analyzed. Five radiologists analyzed standard gray-scale dual-energy CT scans for the presence and degree of cervical disk herniation and spinal nerve root impingement. Readers reassessed scans after 8 weeks using colored VNCa series. Two experienced radiologists set the reference standard in consensus MRI reading sessions. Primary indices of diagnostic accuracy for both CT approaches were sensitivity and specificity, which were compared by application of the McNemar test. RESULTS A total of 57 patients (mean age, 64 ± 11 years; 30 women) were evaluated (337 intervertebral disks). Magnetic resonance imaging indicated a total of 103 cervical disk herniations. The VNCa reconstructions had higher overall sensitivity compared with gray-scale CT (487/515 [95%; 95% confidence interval (CI), 91%-98%] vs 392/515 [76%; 95% CI, 70%-83%]), as well as higher specificity (1107/1170 [95%; 95% CI, 90%-99%] vs 906/1170 [77%; 95% CI, 72%-82%]) for assessing cervical disk herniation (all P < 0.001). The VNCa reconstructions had higher diagnostic accuracy for analyzing spinal nerve root impingement in comparison with gray-scale CT (sensitivity, 195/230 [85%; 95% CI, 79%-90%] vs 115/230 [50%; 95% CI, 40%-59%]; specificity, 1430/1455 [98%; 95% CI, 94%-100%] vs 1325/1455 [91%; 95% CI, 88%-98%]; accuracy, 1625/1685 [96%; 95% CI, 93%-99%] vs 1440/1685 [86%; 95% CI, 82%-90%]; all P < 0.001). CONCLUSIONS Color-coded VNCa series improved the diagnostic accuracy for assessing cervical disk herniation and spinal nerve root impingement compared with standard gray-scale CT.
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Affiliation(s)
- Christian Booz
- From the Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology
| | - Ibrahim Yel
- From the Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology
| | - Simon S Martin
- From the Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology
| | - Lukas Lenga
- From the Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology
| | - Katrin Eichler
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Julian L Wichmann
- From the Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology
| | - Thomas J Vogl
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Moritz H Albrecht
- From the Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology
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Golmohammadi H, Gharekhanloo F, Gharekhanloo M, Jalili E, Pirdehghan A. The accuracy of plain radiography in cervical spine injury. ARCHIVES OF TRAUMA RESEARCH 2021. [DOI: 10.4103/atr.atr_30_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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8
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Garg B, Ahuja K. C-spine clearance in poly-trauma patients: A narrative review. J Clin Orthop Trauma 2021; 12:66-71. [PMID: 33716430 PMCID: PMC7920196 DOI: 10.1016/j.jcot.2020.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 10/08/2020] [Accepted: 10/12/2020] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Bhavuk Garg
- Department of Orthopaedic Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Kaustubh Ahuja
- Department of Orthopaedic Surgery, All India Institute of Medical Sciences, Rishikesh, 249203, Uttarakhand, India
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Tarawneh A, Taqvi S, Salem K, Sahota O. Cervical spine fragility fractures in older people: 5-year experience at a regional spine centre. Age Ageing 2020; 49:1102-1104. [PMID: 32520992 DOI: 10.1093/ageing/afaa088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 03/27/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND cervical spine fractures are particularly prevalent in older people and commonly occur following a fall from standing height or less. Atlanto-axial complex (AAC) and, particularly, odontoid process (OP) fractures are the most prevalent injuries. OBJECTIVE to investigate the incidence and characteristics of cervical spine fractures in older patients presenting to a regional spine centre. METHODS a retrospective review of the clinical records and imaging of all patients aged 70 years and over presenting to a regional spinal unit with a cervical injury over a 5-year period was performed. Patient demographics, mechanism of injury, level of fracture, stability of the fracture, treatment modality, imaging modality and mortality rates were collected and analysed. RESULTS during the period between 2015 and 2019, a total of 209 patients aged 70 years and over were presented to the regional spine unit. The mean age at presentation was 82.4 (±7.5) years. Low-energy trauma was the commonest mechanism of injury (n = 169; 80.9%). MRI was undertaken in a quarter of the patients. One-hundred and fifty-one patients (72.2%) suffered an AAC Injury with OP fractures forming the majority of this group (n = 119; 78.8%). One-hundred and ninety-nine patients were treated conservatively, and the overall 30-day mortality rate was 8.1%. CONCLUSION cervical spine fractures are not uncommon amongst older people and are mostly the result of low-energy trauma and predominantly affect the axial cervical spine. The majority of these injuries are managed conservatively with an orthosis. The fractures nevertheless are a serious injury, with a high mortality rate at 30 days.
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Affiliation(s)
- Ahmad Tarawneh
- Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Syed Taqvi
- Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Khalid Salem
- Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Opinder Sahota
- Department of Healthcare of Older People, Nottingham University Hospitals NHS Trust, Nottingham, UK
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10
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Tariq MB, Wu OC, Agulnick MA, Kasliwal MK. The 100 Most-Cited Papers in Traumatic Injury of the Spine. Neurol India 2020; 68:741-759. [PMID: 32859810 DOI: 10.4103/0028-3886.293470] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Muhammad B Tariq
- Department of Orthopedic Surgery, NYU-Winthrop Hospital, Mineola, New York; Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Osmond C Wu
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Marc A Agulnick
- Department of Orthopedic Surgery, NYU-Winthrop Hospital, Mineola, New York, USA
| | - Manish K Kasliwal
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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Mourad F, Patuzzo A, Tenci A, Turcato G, Faletra A, Valdifiori G, Gobbo M, Maselli F, Milano G. Management of whiplash-associated disorder in the Italian emergency department: the feasibility of an evidence-based continuous professional development course provided by physiotherapists. Disabil Rehabil 2020; 44:2123-2130. [PMID: 32853029 DOI: 10.1080/09638288.2020.1806936] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE The management of whiplash and associated disorders (WAD) in the Italian Health System is still empirical and influenced by a single professional's expertise. Therefore, the purpose of our study is to describe a structured management changes in an Italian emergency department (ED) after an evidence based continuous professional development (CPD) course. METHODS A CPD course was organized by Orthopedic Manipulative Physical Therapists (OMPT) for personnel of ED in the hospital Girolamo Fracastoro (San Bonifacio, Verona, Italy), based on latest scientific evidence. Data regarding the number of X-Rays, computed tomography (CT) scan, orthopaedic referrals, neck collars and WAD IV (i.e., severe diagnosis) before and after the course were compared. RESULTS 3066 cases of WAD have been analyzed in 2016 and 2185 in 2017/2018. The number of X-Rays dropped down from 15.1% to 13.5%; the CT scans increased from 1.3% to 1.9%; the WAD IV diagnosis increased from 0.7% to 1.6%; the orthopaedic referrals dropped from 1.5% to 1.1%; the collars prescription dropped from 8.8% to 2.5%. CONCLUSION An updated framework increased the efficiency of ED's maintaining the same level of safety (i.e., WAD IV diagnosis). Given that, it can also be argued that, in line with other countries, the implementation of an OMPT role within the ED multidisciplinary team is advised also in Italy.Implications for rehabilitationPhysiotherapists were commissioned to organize a management change of patients in an Italian Emergency Department clinical setting for the management of whiplash;Guidelines and other appropriate clinical rules facilitate the delivery of an evidence-based and more appropriate management and care plan;An inter-disciplinary continuous professional development course has the potential to positively influence patients' journey and to optimize the use of departmental resources;The involvement of other health professionals (e.g., Physiotherapists) within the Italian Emergency Department organizational chart might lead to further improvement of service provided.
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Affiliation(s)
| | | | - Andrea Tenci
- Emergency Department, Ospedale "Girolamo Fracastoro", S. Bonifacio (VR). Aulss 9 "Scaligera" della Regione Veneto, Veneto, Italy
| | - Gianni Turcato
- Emergency Department, Ospedale Franz Tappeiner Merano, Bolzano, Italy
| | | | | | - Massimiliano Gobbo
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Filippo Maselli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Campus of Savona, University of Genoa, Savona, Italy.,Sovrintendenza Sanitaria Regionale Puglia INAIL, Bari, Italy
| | - Giuseppe Milano
- Department of Bone and Joint Surgery, Spedali Civili, Brescia, Italy
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Abstract
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
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Affiliation(s)
- Michaël Moeri
- Division of Orthopaedic and Trauma Surgery, Geneva University Hospitals, Switzerland
| | - Dominique A Rothenfluh
- Oxford University Hospitals NHS Foundation Trust, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, UK
| | - Christoph J Laux
- Division of Orthopaedic and Trauma Surgery, Geneva University Hospitals, Switzerland
| | - Dennis E Dominguez
- Division of Orthopaedic and Trauma Surgery, Geneva University Hospitals, Switzerland.,Oxford University Hospitals NHS Foundation Trust, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, UK
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Computed tomography artifacts mimicking type II odontoid fractures: Report of two cases and review of the literature. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2019.100550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Radiological protocol in spinal trauma: literature review and Spinal Cord Society position statement. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 29:1197-1211. [PMID: 31440893 DOI: 10.1007/s00586-019-06112-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 06/29/2019] [Accepted: 08/12/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The Spinal Cord Society constituted a panel tasked with reviewing the literature on the radiological evaluation of spinal trauma with or without spinal cord injury and recommend a protocol. This position statement provides recommendations for the use of each modality, i.e., radiographs (X-rays), computed tomography (CT), magnetic resonance imaging (MRI), as well as vascular imaging, and makes suggestions on identifying or clearing spinal injury in trauma patients. METHODS PubMed was searched for the corresponding keywords from January 1, 1980, to August 1, 2017. A MEDLINE search was subsequently undertaken after applying MeSH filters. Appropriate cross-references were retrieved. Out of the 545 articles retrieved, 105 relevant papers that address the present topic were studied and the extracted content was circulated for further discussions. A draft position statement was compiled and circulated among the panel members via e-mail. The draft was modified by incorporating relevant suggestions to reach a consensus. RESULTS AND CONCLUSION For imaging cervical and thoracolumbar spine trauma patients, CT without contrast is generally considered to be the initial line of imaging and radiographs are required if CT is unavailable or unaffordable. CT screening in polytrauma cases is best done with a multidetector CT by utilizing the reformatted images obtained when scanning the chest, abdomen, and pelvis (CT-CAP). MRI is indicated in cases with neurological involvement and advanced cervical degenerative changes and to determine the extent of soft tissue injury, i.e., disco-ligamentous injuries as well as epidural space compromise. MRI is also usually performed when X-rays and CT are unable to correlate with patient symptomatology. These slides can be retrieved under Electronic Supplementary Material.
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Management of the Spinal Cord Injury in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Squarza S, Uggetti CL, Politi MA, Pescatori LC, Bisogno R, Campi A, Reganati P, Cariati M. C1-C2 fractures in asymptomatic elderly patients with minor head trauma: evaluation with a dedicated head CT protocol. Radiol Bras 2019; 52:17-23. [PMID: 30804611 PMCID: PMC6383526 DOI: 10.1590/0100-3984.2017.0154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective To evaluate the frequency and types of upper cervical spine injuries in
asymptomatic elderly patients undergoing computed tomography (CT) for the
investigation of minor head trauma. Materials and Methods This was a prospective study of 2613 asymptomatic elderly patients with minor
head trauma seen between January 2015 and December 2016. We adopted a
dedicated head CT protocol that included the C1-C2 region. Results Of the 2613 patients analyzed, 33 (1.26%) had upper cervical spine injuries,
corresponding to 8.37% of the 394 patients with trauma-related findings. Of
those 33 patients, 6 had C1 fractures and 27 had C2 fractures. The use of
16- and 128-slice scanners increased the CT dose by 25.0% and 23.7%,
respectively. Conclusion Inclusion of the C1-C2 region in head CT scans allowed us to identify upper
cervical spine injuries in 1.26% of asymptomatic elderly patients with minor
head trauma. The protocol evaluated helps detect potentially
life-threatening injuries and could be adopted for routine use in elderly
individuals with minor head trauma.
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Affiliation(s)
- Silvia Squarza
- Neuroradiology Unit, Radiology Department, Azienda Socio Sanitaria Territoriale Santi Paolo e Carlo, San Carlo Borromeo Hospital, Milano, Italy
| | - Carla Luisa Uggetti
- Neuroradiology Unit, Radiology Department, Azienda Socio Sanitaria Territoriale Santi Paolo e Carlo, San Carlo Borromeo Hospital, Milano, Italy
| | | | | | | | - Adriana Campi
- Neuroradiology Unit, Radiology Department, Azienda Socio Sanitaria Territoriale Santi Paolo e Carlo, San Carlo Borromeo Hospital, Milano, Italy
| | - Paolo Reganati
- Neuroradiology Unit, Radiology Department, Azienda Socio Sanitaria Territoriale Santi Paolo e Carlo, San Carlo Borromeo Hospital, Milano, Italy
| | - Maurizio Cariati
- Neuroradiology Unit, Radiology Department, Azienda Socio Sanitaria Territoriale Santi Paolo e Carlo, San Carlo Borromeo Hospital, Milano, Italy
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Posttraumatic Anatomical Injuries of the Craniovertebral Junction and Treatment Implications: Part I. ACTA NEUROCHIRURGICA. SUPPLEMENT 2019. [PMID: 30610336 DOI: 10.1007/978-3-319-62515-7_42] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Please check the hierarchy of the section headings and correct if necessary.
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Asemota AO, Ahmed AK, Purvis TE, Passias PG, Goodwin CR, Sciubba DM. Analysis of Cervical Spine Injuries in Elderly Patients from 2001 to 2010 Using a Nationwide Database: Increasing Incidence, Overall Mortality, and Inpatient Hospital Charges. World Neurosurg 2018; 120:e114-e130. [DOI: 10.1016/j.wneu.2018.07.228] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 07/24/2018] [Accepted: 07/25/2018] [Indexed: 12/22/2022]
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Parmar KK, Ho KM, Bowles T. Delay in clearing cervical spine injuries in obtunded trauma patients and its implications. TRAUMA-ENGLAND 2018. [DOI: 10.1177/1460408617714821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Kamaljit K Parmar
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Australia
| | - Kwok M Ho
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Australia
- School of Population Health, University of Western Australia, Crawley, Australia
| | - Timothy Bowles
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Australia
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Santos-Nunez G, Lo HS, Kotecha H, Jose J, Abayazeed A. Imaging of Spine Fractures With Emphasis on the Craniocervical Junction. Semin Ultrasound CT MR 2018; 39:324-335. [DOI: 10.1053/j.sult.2018.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Ngatchou W, Beirnaert J, Lemogoum D, Bouland C, Youatou P, Ramadan AS, Sontou R, Alima MB, Plumaker A, Guimfacq V, Bika C, Mols P. Application of the Canadian C-Spine rule and nexus low criteria and results of cervical spine radiography in emergency condition. Pan Afr Med J 2018; 30:157. [PMID: 30455786 PMCID: PMC6235470 DOI: 10.11604/pamj.2018.30.157.13256] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 06/15/2018] [Indexed: 11/30/2022] Open
Abstract
Introduction The Canadian C Spine Rule (CCR) and the National Emergency X-Radiography Utilization Study (Nexus) low criteria are well accepted as guide to help physician in case of cervical blunt trauma. Methods We aimed to evaluate retrospectively the application of these recommendations in our emergency department. Secondly we analyzed the quality of cervical spine radiography (CSR) in an emergency setting. Results 281 patients with cervical blunt trauma were analyzed retrospectively. The CCR and the NEXUS rules were respected in 91.2% and 96.8% of cases respectively. No lesions were found in 96.4% of patient. A lesion was present in 1.1% of patient and suspected in 2.5% of patient. The quality of CSR was adequate in only 37.7% of patient. The poor quality of CSR was due either to the lack of C7 vertebrae visualization in 64.6% or other lower vertebrae in 28%. Other causes included the absence of open mouth view (8%), the absence C1 vertebrae visualization (3.4%), artifact in 2.3% and the absence of lateral view in 0.6% of patient. Conclusion CCR and NEXUS are widely used in our emergency department. The high rate of inadequate CSR reinforces the debate about it’s utility in emergency condition.
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Affiliation(s)
- William Ngatchou
- Department of Emergency and Cardiac Surgery, St Pierre University Hospital, Université Libre de Bruxelles, Belgium
| | - Jeanne Beirnaert
- Department of Emergency St Pierre University Hospital, Université Libre de Bruxelles, Belgium
| | - Daniel Lemogoum
- Department of Cardiology, Erasme University Hospital, Université Libre de Bruxelles, Belgium
| | - Cyril Bouland
- Department of Emergency St Pierre University Hospital, Université Libre de Bruxelles, Belgium
| | - Pierre Youatou
- Department of Emergency St Pierre University Hospital, Université Libre de Bruxelles, Belgium
| | - Ahmed Sabry Ramadan
- Department of Emergency St Pierre University Hospital, Université Libre de Bruxelles, Belgium
| | - Regis Sontou
- Department of Radiology, St Pierre University Hospital, Université Libre de Bruxelles, Belgium
| | - Maimouna Bol Alima
- Department of Cardiac Surgery, St Luc University Hospital, Université Catholique de Louvain, Belgium
| | - Alain Plumaker
- Department of Emergency St Pierre University Hospital, Université Libre de Bruxelles, Belgium
| | - Virginie Guimfacq
- Department of Cardiology, Ixelles University Hospital, Université Libre de Bruxelles, Belgium
| | | | - Pierre Mols
- Department of Emergency St Pierre University Hospital, Université Libre de Bruxelles, Belgium
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Imaging of Spinal Trauma. Emerg Radiol 2018. [DOI: 10.1007/978-3-319-65397-6_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Singh R, Taylor DM, D'Souza D, Gorelik A, Page P, Phal P. Mechanism of Injury and Clinical Variables in Thoracic Spine Fracture: A Case Control Study. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791101800102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective To determine the mechanisms of injury and clinical findings significantly associated with traumatic thoracic spine (T-spine) fractures. Methods This was a case-control study in a tertiary adult trauma centre. Cases were patients admitted with traumatic T-spine fractures between January 1999 and August 2007, inclusive. Each case had two controls matched for gender, age and injury severity. Data were collected from patient medical records and the trauma service database. Factors potentially associated with T-spine fracture were derived from the literature, expert consensus and univariate analysis. Multivariate logistic regression was employed to determine factors significantly associated with T-spine fracture. Results Two hundred and sixty one cases and 512 controls were enrolled. Univariate analysis showed the mechanisms of fall from a height ≥2 meters (m) and motorbike accident ≥60 kilometers per hour were significantly associated with T-spine fracture (p<0.001). The clinical findings of thoracic back pain, tenderness, intoxication, step deformity and abnormal neurological symptoms were also significantly associated with T-spine fracture (p<0.05). Multivariate analysis indicated that falls from a height of ≥2 m and thoracic back pain were significantly and positively associated with T-spine fracture (p<0.001). However, intoxication was negatively associated with T-spine fracture. Conclusions Patients with T-spine injury are significantly more likely to have fallen from a height ≥2 m or to have had thoracic back pain but less likely to be intoxicated. These findings should be validated prospectively prior to development of clinical guidelines for the identification of patients who may benefit from CT screening of the thoracic spine.
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Affiliation(s)
- R Singh
- University of Melbourne, Faculty of Medicine, Parkville, Melbourne, Victoria, Australia 3010
| | | | - D D'Souza
- Toronto General Hospital, Toronto, Canada
| | - A Gorelik
- Royal Melbourne Hospital, Parkville, Melbourne, Victoria, Australia 3050
| | - P Page
- Box Hill, Box Hill Radiology, Victoria, Australia 3128
| | - P Phal
- Royal Melbourne Hospital, Parkville, Melbourne, Victoria, Australia 3050
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Asgeirsdottir TL, Birgisdottir KH, Ólafsdóttir T, Olafsson SP. A compensating income variation approach to valuing 34 health conditions in Iceland. ECONOMICS AND HUMAN BIOLOGY 2017; 27:167-183. [PMID: 28709119 DOI: 10.1016/j.ehb.2017.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 06/06/2017] [Accepted: 06/06/2017] [Indexed: 06/07/2023]
Abstract
Using data from an Icelandic health-and-lifestyle survey carried out in 2007, 2009, and 2012, we employ a compensating income variation (CIV) approach to estimate the monetary value sufficient to compensate individuals for the presence of various sub-optimal health conditions. This method is inexpensive and easy on subjects and has been applied to several desiderata that do not have revealed market prices. The CIV literature is, however, still limited in its application to health and thus information about its suitability is limited. With the aim of shedding light on the method́s appropriateness we thus provide a broad-view analysis including a spectrum of diseases and conditions that can be held up against more traditionally used methods. CIV for physical conditions vary greatly, but paralysis, fibromyalgia, chronic back pain, rheumatoid arthritis, urinary incontinence, severe headache and thyroid disease were among those consistently associated with substantial well-being reductions. Mental-health results using this method should be read with caution. The societal value of health interventions is multidimensional, including for example increased productivity in the population. However, one of the main positive aspects of increased health is undoubtedly the increased well-being of the treated subjects. Such quality-of-life effects should thus preferably be taken into account. For this reason, information on the value individuals place on recovery from various sub-optimal health conditions is useful when it comes to prioritizing scarce capital in the health sector. It is therefore vital to estimate the importance individuals place on various health states and hold them up against each other. Furthermore, this paper has scientific value as it sheds light on attributes of a potentially useful method in health evaluations.
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Affiliation(s)
| | | | - Thorhildur Ólafsdóttir
- Faculty of Economics, University of Iceland, Oddi v/Sturlugotu, 101 Reykjavik, Iceland; Faculty of Business Administration, University of Iceland, Gimli v/Sturlugotu, 101 Reykjavik, Iceland
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Molière S, Zaragori-Benedetti C, Ehlinger M, Le Minor JM, Kremer S, Bierry G. Evaluation of Paraspinal Fat Pad as an Indicator of Posterior Ligamentous Complex Injury in Cervical Spine Trauma. Radiology 2017; 282:790-797. [DOI: 10.1148/radiol.2016160330] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Sébastien Molière
- From the Departments of Radiology (S.M., C.Z.B., J.M.L.M., S.K., G.B.) and Orthopedic Surgery (M.E.), University Hospital of Strasbourg, 10 avenue Molière, F-67098 Strasbourg, France; and ICube Laboratory (M.E., J.M.L.M., S.K., G.B.) and Institute of Anatomy (J.M.L.M.), University of Strasbourg, Strasbourg, France
| | - Cyril Zaragori-Benedetti
- From the Departments of Radiology (S.M., C.Z.B., J.M.L.M., S.K., G.B.) and Orthopedic Surgery (M.E.), University Hospital of Strasbourg, 10 avenue Molière, F-67098 Strasbourg, France; and ICube Laboratory (M.E., J.M.L.M., S.K., G.B.) and Institute of Anatomy (J.M.L.M.), University of Strasbourg, Strasbourg, France
| | - Matthieu Ehlinger
- From the Departments of Radiology (S.M., C.Z.B., J.M.L.M., S.K., G.B.) and Orthopedic Surgery (M.E.), University Hospital of Strasbourg, 10 avenue Molière, F-67098 Strasbourg, France; and ICube Laboratory (M.E., J.M.L.M., S.K., G.B.) and Institute of Anatomy (J.M.L.M.), University of Strasbourg, Strasbourg, France
| | - Jean-Marie Le Minor
- From the Departments of Radiology (S.M., C.Z.B., J.M.L.M., S.K., G.B.) and Orthopedic Surgery (M.E.), University Hospital of Strasbourg, 10 avenue Molière, F-67098 Strasbourg, France; and ICube Laboratory (M.E., J.M.L.M., S.K., G.B.) and Institute of Anatomy (J.M.L.M.), University of Strasbourg, Strasbourg, France
| | - Stéphane Kremer
- From the Departments of Radiology (S.M., C.Z.B., J.M.L.M., S.K., G.B.) and Orthopedic Surgery (M.E.), University Hospital of Strasbourg, 10 avenue Molière, F-67098 Strasbourg, France; and ICube Laboratory (M.E., J.M.L.M., S.K., G.B.) and Institute of Anatomy (J.M.L.M.), University of Strasbourg, Strasbourg, France
| | - Guillaume Bierry
- From the Departments of Radiology (S.M., C.Z.B., J.M.L.M., S.K., G.B.) and Orthopedic Surgery (M.E.), University Hospital of Strasbourg, 10 avenue Molière, F-67098 Strasbourg, France; and ICube Laboratory (M.E., J.M.L.M., S.K., G.B.) and Institute of Anatomy (J.M.L.M.), University of Strasbourg, Strasbourg, France
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Krishnan UC, Byanyima RK, Faith A, Kamulegeya A. Maxillofacial injuries among trauma patients undergoing head computerized tomography; A Ugandan experience. Int J Crit Illn Inj Sci 2017; 7:236-240. [PMID: 29291177 PMCID: PMC5737066 DOI: 10.4103/2229-5151.219950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Aim: The aim of this study was to investigate epidemiological features of maxillofacial fractures within trauma patients who had head and neck computed tomography (CT) scan at the Mulago National referral hospital. Methods: CT scan records of trauma patients who had head scans at the Department of Radiology over 1-year period were accessed. Data collected included sociodemographic factors, type and etiology of injury, and concomitant maxillofacial injuries. Results: A total of 1330 trauma patients underwent head and neck CT scan in the 1-year study period. Out of these, 130 were excluded due to incomplete or unclear records and no evidence of injury. Of the remaining 1200, 32% (387) had maxillofacial fractures. The median age of the patients with maxillofacial fractures was 28 (range = 18–80) years and 18–27 age group was most common at 47.5%. Road traffic accidents constituted 49.1% of fractures. The single most affected isolated bone was the frontal bone (23%). The number of maxillofacial bones fractured was predicted by age group (df = 3 F = 5.358, P = 0.001), association with other fractures (df = 1 F = 5.317, P = 0.03). Conclusions: Good matched case–control prospective studies are needed to enable us tease out the finer difference in the circumstances and pattern of injury if we are to design appropriate preventive measures.
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Affiliation(s)
| | | | - Ameda Faith
- Department of Pathology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Adriane Kamulegeya
- Department of Dentistry, Makerere University College of Health Sciences, Kampala, Uganda
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Utility of computed tomographic imaging of the cervical spine in trauma evaluation of ground-level fall. J Trauma Acute Care Surg 2016; 81:339-44. [PMID: 27454805 DOI: 10.1097/ta.0000000000001073] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Computed tomography (CT) of the cervical spine (C-spine) is routinely ordered for low-risk mechanisms of injury, including ground-level fall. Two commonly used clinical decision rules (CDRs) to guide C-spine imaging in trauma are the National Emergency X-Radiography Utilization Study (NEXUS) and the Canadian Cervical Spine Rule for Radiography (CCR). METHODS Retrospective cross-sectional study of 3,753 consecutive adult patients presenting to an urban Level I emergency department who received C-spine CT scans were obtained over a 6-month period. The primary outcome of interest was prevalence of C-spine fracture. Secondary outcomes included fracture stability, appropriateness of imaging by NEXUS and CCR criteria, and estimated radiation dose exposure and costs associated with C-spine imaging studies. RESULTS Of the 760 patients meeting inclusion criteria, 7 C-spine fractures were identified (0.92% ± 0.68%). All fractures were identified by NEXUS and CCR criteria with 100% sensitivity. Of all these imaging studies performed, only 69% met NEXUS indications for imaging (50% met CCR indications). C-spine CT scans in patients not meeting CDR indications were associated with costs of $15,500 to $22,000 by NEXUS ($14,600-$25,600 by CCR) in this single center during the 6-month study period. CONCLUSION For ground-level fall, C-spine CT is overused. The consistent application of CDR criteria would reduce annual nationwide imaging costs in the United States by $6.8 to $9.6 million based on NEXUS ($6.4-$15.6 million based on CCR) and would reduce population radiation dose exposure by 0.8 to 1.1 million mGy based on NEXUS (0.7-1.9 million mGy based on CCR) if applied across all Level I trauma centers. Greater use of evidence-based CDRs plays an important role in facilitating emergency department patient management and reducing systemwide radiation dose exposure and imaging expenditures. LEVEL OF EVIDENCE Diagnostic study, level III.
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Little G, Kelly M, Glucksman E. Critical pitfalls in the immediate assessment of the trauma patient. TRAUMA-ENGLAND 2016. [DOI: 10.1177/146040860100300106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In the immediate assessment of trauma patients, critical pitfalls exist that may interfere with optimal clinical care. Failure to recognize the need for early anaesthesia and endotracheal intubation may put the patient at unnecessary risk and delay the assessment and treatment process. Pressure to clear the cervical spine may lead to inadequate imaging and premature removal of neck immobilization devices. The limitations of the initial chest X-ray in diagnosing pneumothoraces may not be appreciated and needle thoracentesis may be ineffective. ‘Springing’ the pelvis to assess for instability may cause life-threatening haemorrhage and should not be done prior to the initial pelvic X-ray. Log rolling may dislodge crucial clot formation and promote bleeding, and should only be used for diagnostic purposes. Applying clinical common sense to the assessment of trauma patients may avoid the pitfalls whilst allowing the clinician to operate within internationally agreed assessment and treatment frameworks.
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Affiliation(s)
- George Little
- Accident and Emergency Department, King’s College Hospital, London, UK,
| | - Michael Kelly
- Accident and Emergency Department, King’s College Hospital, London, UK
| | - E Glucksman
- Accident and Emergency Department, King’s College Hospital, London, UK
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Bingol O, Ayrık C, Kose A, Bozkurt S, Narcı H, Ovla D, Duce MN. Retrospective analysis of whole-body multislice computed tomography findings taken in trauma patients. Turk J Emerg Med 2016; 15:116-21. [PMID: 27239608 PMCID: PMC4878127 DOI: 10.1016/j.tjem.2015.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 12/10/2014] [Accepted: 12/26/2014] [Indexed: 11/23/2022] Open
Abstract
Objectives Using whole-body multislice computed tomography (MSCT) excessively or with irrelevant indications can be seen in many centers. The aim of this study was to analyze retrospectively the MSCT findings in trauma patients admitted to the emergency department. Methods Records of the patients who have applied to the emergency department due to blunt trauma in a 12 month period and whose whole body MSCT images have been taken, were evaluated using the “Nucleus Medical Information System”. Results The most frequent type of trauma was traffic accidents in 61.4%, falling down from the height in 22.4%, and motorcycle accidents in 11.4% of patients. Of the patients, 25.2% were discharged from the emergency, while 73.8% were hospitalized. At least one CT findings associated with trauma was present in 61.4% of our patients. Pathological findings in MSCT were most frequently detected in the head and face (35.3%) and thoracic (28.6%) regions, respectively. The most common finding in the head and face region was fractures. The most common pathological findings in the thoracic region were pulmonary contusion and rib fractures. A significant relationship was detected between trauma type and spinal MSCT result (p < 0.001). In a large percentage of the patients, MSCT findings were normal in the abdominal region and genitourinary system. Vertebral fractures were most frequently detected in the thoracolumbar region. Conclusions In our study, our rate of negative CT was found to be 38.6%, which is a higher ratio compared to other studies conducte on this topic.
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Affiliation(s)
- Ozlem Bingol
- Department of Emergency Medicine, Mersin University, Faculty of Medicine, Mersin, Turkey
| | - Cuneyt Ayrık
- Department of Emergency Medicine, Mersin University, Faculty of Medicine, Mersin, Turkey
| | - Ataman Kose
- Department of Emergency Medicine, Mersin University, Faculty of Medicine, Mersin, Turkey
- Corresponding Author.
| | - Seyran Bozkurt
- Department of Emergency Medicine, Mersin University, Faculty of Medicine, Mersin, Turkey
| | - Huseyin Narcı
- Department of Emergency Medicine, Mersin University, Faculty of Medicine, Mersin, Turkey
| | - Didem Ovla
- Department of Biostatistics, Mersin University, Faculty of Medicine, Mersin, Turkey
| | - Meltem Nass Duce
- Department of Radiology, Mersin University, Faculty of Medicine, Mersin, Turkey
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Patro SN, Chakraborty S, Sheikh A. The use of adaptive statistical iterative reconstruction (ASiR) technique in evaluation of patients with cervical spine trauma: impact on radiation dose reduction and image quality. Br J Radiol 2016; 89:20150082. [PMID: 26882825 DOI: 10.1259/bjr.20150082] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the impact of adaptive statistical iterative reconstruction (ASiR) technique on the image quality and radiation dose reduction. The comparison was made with the traditional filtered back projection (FBP) technique. METHODS We retrospectively reviewed 78 patients, who underwent cervical spine CT for blunt cervical trauma between 1 June 2010 and 30 November 2010. 48 patients were imaged using traditional FBP technique and the remaining 30 patients were imaged using the ASiR technique. The patient demographics, radiation dose, objective image signal and noise were recorded; while subjective noise, sharpness, diagnostic acceptability and artefacts were graded by two radiologists blinded to the techniques. RESULTS We found that the ASiR technique was able to reduce the volume CT dose index, dose-length product and effective dose by 36%, 36.5% and 36.5%, respectively, compared with the FBP technique. There was no significant difference in the image noise (p = 0.39), signal (p = 0.82) and signal-to-noise ratio (p = 0.56) between the groups. The subjective image quality was minimally better in the ASiR group but not statistically significant. There was excellent interobserver agreement on the subjective image quality and diagnostic acceptability for both groups. CONCLUSION The use of ASiR technique allowed approximately 36% radiation dose reduction in the evaluation of cervical spine without degrading the image quality. ADVANCES IN KNOWLEDGE The present study highlights that the ASiR technique is extremely helpful in reducing the patient radiation exposure while maintaining the image quality. It is highly recommended to utilize this novel technique in CT imaging of different body regions.
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Affiliation(s)
- Satya N Patro
- 1 Neuroradiology, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Santanu Chakraborty
- 2 Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Adnan Sheikh
- 3 The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
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Blackmore CC, Castro A. Improving the Quality of Imaging in the Emergency Department. Acad Emerg Med 2015; 22:1385-92. [PMID: 26568040 DOI: 10.1111/acem.12816] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 07/06/2015] [Indexed: 11/29/2022]
Abstract
Imaging is critical for the care of emergency department (ED) patients. However, much of the imaging performed for acute care today is overutilization, creating substantial cost without significant benefit. Further, the value of imaging is not easily defined, as imaging only affects outcomes indirectly, through interaction with treatment. Improving the quality, including appropriateness, of emergency imaging requires understanding of how imaging contributes to patient care. The six-tier efficacy hierarchy of Fryback and Thornbury enables understanding of the value of imaging on multiple levels, ranging from technical efficacy to medical decision-making and higher-level patient and societal outcomes. The imaging efficacy hierarchy also allows definition of imaging quality through the Institute of Medicine (IOM)'s quality domains of safety, effectiveness, patient-centeredness, timeliness, efficiency, and equitability and provides a foundation for quality improvement. In this article, the authors elucidate the Fryback and Thornbury framework to define the value of imaging in the ED and to relate emergency imaging to the IOM quality domains.
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Affiliation(s)
- C. Craig Blackmore
- The Center for Healthcare Improvement Science and Department of Radiology; Virginia Mason Medical Center; Seattle WA
| | - Alexandra Castro
- The Department of Emergency Medicine; University of Pittsburgh; Pittsburgh PA
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Outcomes of pediatric patients with persistent midline cervical spine tenderness and negative imaging result after trauma. J Trauma Acute Care Surg 2015; 79:822-7. [DOI: 10.1097/ta.0000000000000847] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dahlquist RT, Fischer PE, Desai H, Rogers A, Christmas AB, Gibbs MA, Sing RF. Femur fractures should not be considered distracting injuries for cervical spine assessment. Am J Emerg Med 2015; 33:1750-4. [PMID: 26346048 DOI: 10.1016/j.ajem.2015.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 08/07/2015] [Accepted: 08/07/2015] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION The National Emergency X-Radiography Utilization Study (NEXUS) clinical decision rule is extremely sensitive for clearance of cervical spine (C-spine) injury in blunt trauma patients with distracting injuries. OBJECTIVES We sought to determine whether the NEXUS criteria would maintain sensitivity for blunt trauma patients when femur fractures were not considered a distracting injury and an absolute indication for diagnostic imaging. METHODS We retrospectively analyzed blunt trauma patients with at least 1 femur fracture who presented to our emergency department as trauma activations from 2009 to 2011 and underwent C-spine injury evaluation. Presence of C-spine injury requiring surgical intervention was evaluated. RESULTS Of 566 trauma patients included, 77 (13.6%) were younger than 18 years. Cervical spine injury was diagnosed in 53 (9.4%) of 566. A total of 241 patients (42.6%) had positive NEXUS findings in addition to distracting injury; 51 (21.2%) of these had C-spine injuries. Of 325 patients (57.4%) with femur fractures who were otherwise NEXUS negative, only 2 (0.6%) had C-spine injuries (95% confidence interval [CI], 0.2%-2.2%); both were stable and required no operative intervention. Use of NEXUS criteria, excluding femur fracture as an indication for imaging, detected all significant injuries with a sensitivity for any C-spine injury of 96.2% (95% CI, 85.9%-99.3%) and negative predictive value of 99.4% (95% CI, 97.6%-99.9%). CONCLUSIONS In our patient population, all significant C-spine injuries were identified by NEXUS criteria without considering the femur fracture a distracting injury and indication for computed tomographic imaging. Reconsidering femur fracture in this context may decrease radiation exposure and health care expenditure with little risk of missed diagnoses.
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Affiliation(s)
| | - Peter E Fischer
- Carolinas Medical Center, Carolinas HealthCare System, Charlotte, NC
| | - Harsh Desai
- University of Maryland School of Medicine, Baltimore, MD
| | - Amelia Rogers
- University of Maryland School of Medicine, Baltimore, MD
| | | | - Michael A Gibbs
- Carolinas Medical Center, Carolinas HealthCare System, Charlotte, NC
| | - Ronald F Sing
- Carolinas Medical Center, Carolinas HealthCare System, Charlotte, NC.
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Agrawal D, Sinha TP, Bhoi S. Assessment of ultrasound as a diagnostic modality for detecting potentially unstable cervical spine fractures in pediatric severe traumatic brain injury: A feasibility study. J Pediatr Neurosci 2015; 10:119-22. [PMID: 26167212 PMCID: PMC4489052 DOI: 10.4103/1817-1745.159196] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background: Early cervical spine clearance is extremely important in unconscious trauma patients and may be difficult to achieve in emergency setting. Objectives: The aim of this study was to assess the feasibility of standard portable ultrasound in detecting potentially unstable cervical spine injuries in severe traumatic brain injured (TBI) patients during initial resuscitation. Materials and Methods: This retro-prospective pilot study carried out over 1-month period (June–July 2013) after approval from the institutional ethics committee. Initially, the technique of cervical ultrasound was standardized by the authors and tested on ten admitted patients of cervical spine injury. To assess feasibility in the emergency setting, three hemodynamically stable pediatric patients (≦18 years) with isolated severe head injury (Glasgow coma scale ≤8) coming to emergency department underwent an ultrasound examination. Results: The best window for the cervical spine was through the anterior triangle using the linear array probe (6–13 MHz). In the ten patients with documented cervical spine injury, bilateral facet dislocation at C5–C6 was seen in 4 patients and at C6–C7 was seen in 3 patients. C5 burst fracture was present in one and cervical vertebra (C2) anterolisthesis was seen in one patient. Cervical ultrasound could easily detect fracture lines, canal compromise and ligamental injury in all cases. Ultrasound examination of the cervical spine was possible in the emergency setting, even in unstable patients and could be done without moving the neck. Conclusions: Cervical ultrasound may be a useful tool for detecting potentially unstable cervical spine injury in TBI patients, especially those who are hemodynamically unstable.
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Affiliation(s)
- Deepak Agrawal
- Department of Neurosurgery, JPNA Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Tej Prakash Sinha
- Department of Emergency Medicine, JPNA Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjeev Bhoi
- Department of Emergency Medicine, JPNA Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
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Giacomini G, Miranda JRA, Pavan ALM, Duarte SB, Ribeiro SM, Pereira PCM, Alves AFF, de Oliveira M, Pina DR. Quantification of Pulmonary Inflammatory Processes Using Chest Radiography: Tuberculosis as the Motivating Application. Medicine (Baltimore) 2015; 94:e1044. [PMID: 26131814 PMCID: PMC4504622 DOI: 10.1097/md.0000000000001044] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The purpose of this work was to develop a quantitative method for evaluating the pulmonary inflammatory process (PIP) through the computational analysis of chest radiography exams in posteroanterior (PA) and lateral views. The quantification procedure was applied to patients with tuberculosis (TB) as the motivating application.A study of high-resolution computed tomography (HRCT) examinations of patients with TB was developed to establish a relation between the inflammatory process and the signal difference-to-noise ratio (SDNR) measured in the PA projection. A phantom essay was used to validate this relation, which was implemented using an algorithm that is able to estimate the volume of the inflammatory region based solely on SDNR values in the chest radiographs of patients.The PIP volumes that were quantified for 30 patients with TB were used for comparisons with direct HRCT analysis for the same patient. The Bland-Altman statistical analyses showed no significant differences between the 2 quantification methods. The linear regression line had a correlation coefficient of R = 0.97 and P < 0.001, showing a strong association between the volume that was determined by our evaluation method and the results obtained by direct HRCT scan analysis.Since the diagnosis and follow-up of patients with TB is commonly performed using X-rays exams, the method developed herein can be considered an adequate tool for quantifying the PIP with a lower patient radiation dose and lower institutional cost. Although we used patients with TB for the application of the method, this method may be used for other pulmonary diseases characterized by a PIP.
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Affiliation(s)
- Guilherme Giacomini
- From Departamento de Física e Biofísica, Instituto de Biociências de Botucatu-IBB, UNESP-Univ Estadual Paulista, Botucatu/SP, Brazil (GG, JRM, ALMP, AFFA, MDO); Departamento de Doenças Tropicais e Diagnóstico por Imagem, Faculdade de Medicina de Botucatu, UNESP-Univ Estadual Paulista, Botucatu/SP, Brazil (SMR, PCMP, DRP); and Centro Brasileiro de Pesquisas Físicas-CBPF/MCT, Rio de Janeiro/RJ, Brazil (SBD)
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Imura T, Inoue G, Nakazawa T, Saito W, Takaso M. Surgical treatment of an atlantoaxial fracture after a delayed diagnosis in a comatose patient. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 24 Suppl 4:S623-7. [PMID: 25827309 DOI: 10.1007/s00586-015-3907-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 03/23/2015] [Accepted: 03/26/2015] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Case report. OBJECTIVE To report a case of fractures of the right lateral atlantoaxial joint and C2 body diagnosed more than 5 months after injury. Misdiagnosis of an injury to the cervical spine has been reported frequently. For patients in whom cervical injury is suspected, the primary screening modality is axial CT from the occiput to T1 with sagittal and coronal reconstructions. The inadequacy of this radiological evaluation could delay diagnosis of fractures and lead to unnecessary surgical treatment of the cervical spine. METHODS We report the case of a 74-year-old woman with an old, displaced combined fracture of the C1 and C2 right facet joint. In this case, CT of the brain was evaluated at the time of injury, but not CT of the cervical spine. As a consequence, diagnosis was delayed and surgical treatment was necessary. RESULTS We performed posterior fusion surgery for C1 and C2. A pedicle screw was not inserted on both sides of C2, because of destruction of the insertional point on the right side and a high-riding VA on the left. Alternatively, a lamina screw and hook were used for C2, fixed with lateral mass screws on C1, with a bone graft harvested from the iliac crest. CONCLUSIONS To avoid unnecessary surgery, surgeons should recognize the possibility of cervical fractures that cannot be detected without CT, especially in patients who are comatose at injury. Atlantoaxial fixation with a hook and lamina screw in C2 is an option for old upper cervical fractures in cases where a pedicle screw cannot be inserted into C2.
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Affiliation(s)
- Takayuki Imura
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
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Liu K, Xie F, Wang D, Guo L, Qi Y, Tian J, Zhao B, Chhabra A. Reference ranges for atlantodental interval in adults and its variation with age and gender in a large series of subjects on multidetector computed tomography. Acta Radiol 2015; 56:465-70. [PMID: 24782570 DOI: 10.1177/0284185114530284] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The atlanto-dental interval measurement in the cervical spine in young adults has been reported on multidetector computed tomography (MDCT), but has not been systematically assessed in all ages. PURPOSE To evaluate the reference ranges for the atlanto-dental interval (ADI) in a large sample of adult patients on MDCT and to analyze the relationships of these measurements with gender and age of the patients as well as inter-observer performance. MATERIAL AND METHODS First, a consecutive series of 700 Chinese patients aged over 18 years undergoing an upper cervical MDCT scan were divided equally into seven age groups. Second, the mid-sagittal image of the atlanto-dental joint was chosen for measurement and ADI was defined as the distance intercepted from the segment line linking the center of anterior atlas tubercle with that of posterior tubercle. Third, the correlation of ADI with age and gender was analyzed using linear regression analysis. Finally, the inter-observer performance was assessed using Bland and Altman's limits of agreement. RESULTS The ADI was 1.77 ± 0.39 mm, 1.61 ± 0.37 mm, 1.58 ± 0.36 mm, 1.41 ± 0.29 mm, 1.31 ± 0.29 mm, 1.34 ± 0.28 mm, and 1.06 ± 0.47 mm in the age groups 18-24 years, 25-29 years, 30-39 years, 40-49 years, 50-59 years, 60-69 years, and older than 70 years, respectively. The range of ADI was 0.85-3.12 mm in the age group 18-39 years, 0.71-2.55 mm in the age group 40-59 years, and 0.00-2.37 mm in the age group older than 60 years. There was no difference between gender and ADI (r = 0.00, P = 1.000). ADI decreased linearly with age (r = -0.511, P = 0.000). The inter-observer performance was reliable. CONCLUSION ADI measurements on MDCT linearly decrease with increasing age, and these are not affected by gender in adult patients. Different reference values might be used at different ages when diagnosing atlantoaxial anterior dislocation or subluxation.
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Affiliation(s)
- Kai Liu
- Shandong Medical Imaging Research Institute, Shandong University, Jinan, PR China
| | - Fubo Xie
- Department of Radiology, Qilu Hospital, Shandong University, Jinan, PR China
| | - Daocai Wang
- Shandong Medical Imaging Research Institute, Shandong University, Jinan, PR China
| | - Lingfei Guo
- Shandong Medical Imaging Research Institute, Shandong University, Jinan, PR China
| | - Yuangang Qi
- Department of Radiotherapy, Shandong Tumor Hospital, Jinan, PR China
| | - Jun Tian
- Shandong Medical Imaging Research Institute, Shandong University, Jinan, PR China
| | - Bin Zhao
- Shandong Medical Imaging Research Institute, Shandong University, Jinan, PR China
| | - Avneesh Chhabra
- Department of Musculoskeletal Radiology & Orthopedic Surgery, UT Southwestern Medical Center, Johns Hopkins University, Dallas, TX, USA
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Kanwar R, Delasobera BE, Hudson K, Frohna W. Emergency department evaluation and treatment of cervical spine injuries. Emerg Med Clin North Am 2015; 33:241-82. [PMID: 25892721 DOI: 10.1016/j.emc.2014.12.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Most spinal cord injuries involve the cervical spine, highlighting the importance of recognition and proper management by emergency physicians. Initial cervical spine injury management should follow the ABCDE (airway, breathing, circulation, disability, exposure) procedure detailed by Advanced Trauma Life Support. NEXUS (National Emergency X-Radiography Utilization Study) criteria and Canadian C-spine Rule are clinical decision-making tools providing guidelines of when to obtain imaging. Computed tomography scans are the preferred initial imaging modality. Consider administering intravenous methylprednisolone after discussion with the neurosurgical consultant in patients who present with spinal cord injuries within 8 hours.
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Affiliation(s)
- Rajdeep Kanwar
- Department of Emergency Medicine, MedStar Washington Hospital Center, MedStar Georgetown University/Washington Hospital Center Emergency Medicine Residency, 110 Irving Street Northwest, NA-1177, Washington, DC 20010, USA.
| | - Bronson E Delasobera
- Department of Emergency Medicine, MedStar Washington Hospital Center, 110 Irving Street Northwest, NA-1177, Washington, DC 20010, USA.
| | - Korin Hudson
- Department of Emergency Medicine, MedStar Georgetown University Hospital, 3800 Reservoir Road Northwest, Ground Floor CCC Building, Washington, DC 20007, USA
| | - William Frohna
- Department of Emergency Medicine, MedStar Washington Hospital Center, MedStar Georgetown University/Washington Hospital Center Emergency Medicine Residency, 110 Irving Street Northwest, NA-1177, Washington, DC 20010, USA
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The benefit of neck computed tomography compared with its harm (risk of cancer). J Trauma Acute Care Surg 2015; 78:126-31. [PMID: 25539213 DOI: 10.1097/ta.0000000000000465] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The purpose of this study was to compare the benefit of neck computed tomography (CT) of identifying important cervical spine injuries (CSIs) with its harm of radiation exposure and cancer risk. METHODS A PubMed search for published studies relating to CSI in trauma, cervical spine imaging, CT, and cancer risk was conducted. Article abstracts were reviewed, and selected published studies relating to the study objective were retrieved. RESULTS Of 100,000 trauma patients, neck CT scans were obtained in 3,767 to 26,785 patients. Of 100,000 patients with trauma on whom a neck CT scan was performed, a CSI was identified in 2,470 to 33,898 patients. Clinically important CSI ranged from 4,724 to 27,119 per 100,000 CT scans. For every 100,000 neck CT scans performed, additional cancer cases occur in a low end estimate of a thyroid cancer cases to a high end estimate of 100 male and 700 female cancer cases. In females, cancer risks are higher than in males, and these are closer to, but still less than, the incidence of clinically important CSI found by CT. CONCLUSION CT's benefit of identifying important CSIs in the published studies exceeds its cancer harm risk. However, at their extremes, the numbers are disturbingly close. Limiting neck CT scanning to a higher-risk group would increase the gap between benefit and harm, whereas performing CT routinely on low-risk cases approaches a point where its harm equals or exceeds its benefit. LEVEL OF EVIDENCE Systematic review, level IV.
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Hannon M, Mannix R, Dorney K, Mooney D, Hennelly K. Pediatric Cervical Spine Injury Evaluation After Blunt Trauma: A Clinical Decision Analysis. Ann Emerg Med 2015; 65:239-47. [DOI: 10.1016/j.annemergmed.2014.09.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 08/18/2014] [Accepted: 09/02/2014] [Indexed: 02/03/2023]
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Cervical spine clearance protocols in Level I, II, and III trauma centers in California. Spine J 2015; 15:398-404. [PMID: 25546512 DOI: 10.1016/j.spinee.2014.12.142] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2013] [Revised: 12/02/2014] [Accepted: 12/19/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Cervical spine clearance protocols were developed to standardize the clearance of the cervical spine after blunt trauma and prevent secondary neurologic injuries. The degree of incorporation of evidence-based guidelines into protocols at trauma centers in California is unknown. PURPOSE To evaluate the cervical spine clearance protocols in all trauma centers of California. STUDY DESIGN An observational cross-sectional study. PATIENT SAMPLE Included from Level I, II, III trauma centers in California. OUTCOME MEASURES The self-reported outcomes of each trauma center's cervical spine clearance protocols were assessed. METHODS Level I (n=15), II (n=30), and III (n=11) trauma centers in California were contacted. Each available protocol was reviewed for four scenarios: clearing the asymptomatic patient, the initial imaging modality used in patients not amenable to clinical clearance, and the management strategies for patients with persistent neck pain with a negative computed tomography (CT) scan and those who are obtunded. Results were compared with the 2009 Eastern Association for the Surgery of Trauma (EAST) cervical spine clearance guidelines. RESULTS The response rate was 96%. Sixty-three percent of California's trauma centers (Level I, 93%; Level II, 60%; Level III, 27%) had written cervical spine clearance protocols. For asymptomatic patients, 83% of Level I and 61% of Level II centers used National Emergency X-Radiography Utilization Study criteria with/without painless range of motion. For those requiring imaging, 67% of Level I and 56% of Level II centers stated a CT scan should be the first line of imaging. For obtunded patients and patients with persistent neck pain and a negative CT scan, more than 90% of Level I and more than 70% of Level II trauma centers incorporated the 2009 EAST recommendations. No institution recommended passive flexion-extension radiographs for the obtunded patient. CONCLUSIONS Written cervical spine clearance protocols exist in 63% of California's trauma centers and only 51% of the centers have protocols that follow current evidence-based guidelines. Standardization and utilization of these protocols should be encouraged to prevent missed injuries and secondary neurologic injuries.
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Brinckman MA, Chau C, Ross JS. Marrow edema variability in acute spine fractures. Spine J 2015; 15:454-60. [PMID: 25304448 DOI: 10.1016/j.spinee.2014.09.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Revised: 07/22/2014] [Accepted: 09/30/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The presence or absence of marrow edema is used in the assessment of fracture acuity in magnetic resonance imaging (MRI). We have observed variability in the degree of marrow edema in acute trauma. Our aim was to characterize the utility of marrow edema in fracture detection and fracture acuity on MRI. We hypothesized that only vertebral body compression injuries reliably generate marrow edema and that distraction injuries or fractures without compression do not reliably generate marrow edema and may give a false negative MRI examination. PURPOSE To characterize the utility of marrow edema in fracture detection and fracture acuity on MRI. STUDY DESIGN Two-year single-center retrospective review of marrow edema in patients evaluated by both computed tomography (CT) and MRI in acute trauma setting. PATIENT SAMPLE The final study cohort consisted of 163 patients (mean age, 54.5 years; standard deviation, 23.5 years; range, 8-94 years; 85 men and 78 women). OUTCOME MEASURES A physiologic measure of marrow edema as assessed by T2-signal hyperintensity on short tau inversion recovery sequence MRI examination. METHODS After institutional review board approval, we conducted a retrospective review of 1,215 patients who were evaluated at our hospital for suspected spine trauma with a combination of CT and MRI. Patients were assessed for fracture presence, location, type, and absence or degree of marrow edema. RESULTS The investigation identified 189/1,215 patients who had acute fractures on CT, subsequently imaged within 48 hours by MRI. A total of 94/288 acute fractures did not generate marrow edema. There were 63 patients (83 acute fractures) whose mechanism of injury resulted exclusively in acute fractures with no marrow edema. A statistically significant difference in marrow edema was observed with acute vertebral body compression fractures compared with acute fractures with distraction or fractures without compression. Moreover, certain fracture types were identified that often generate little or no marrow edema in acute trauma setting. CONCLUSIONS There is variability in the presence or degree of marrow edema on MRI evaluation after traumatic injury. Only fractures derived from vertebral body compression reliably generate marrow edema. Fractures without compression and/or fractures with distraction do not reliably generate marrow edema and can lead to a false negative MRI. An awareness of fracture types that produce more or less marrow edema can be beneficial when evaluating fractures by MRI.
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Affiliation(s)
- Mark A Brinckman
- Department of Neuroradiology, Barrow Neurological Institute, St. Joseph Hospital and Medical Center 350 W. Thomas Rd Phoenix, AZ 85013, USA.
| | - Cam Chau
- Department of Neuroradiology, Barrow Neurological Institute, St. Joseph Hospital and Medical Center 350 W. Thomas Rd Phoenix, AZ 85013, USA
| | - Jeffrey S Ross
- Department of Neuroradiology, Barrow Neurological Institute, St. Joseph Hospital and Medical Center 350 W. Thomas Rd Phoenix, AZ 85013, USA
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Rubin GD. Computed tomography: revolutionizing the practice of medicine for 40 years. Radiology 2015; 273:S45-74. [PMID: 25340438 DOI: 10.1148/radiol.14141356] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Computed tomography (CT) has had a profound effect on the practice of medicine. Both the spectrum of clinical applications and the role that CT has played in enhancing the depth of our understanding of disease have been profound. Although almost 90 000 articles on CT have been published in peer-reviewed journals over the past 40 years, fewer than 5% of these have been published in Radiology. Nevertheless, these almost 4000 articles have provided a basis for many important medical advances. By enabling a deepened understanding of anatomy, physiology, and pathology, CT has facilitated key advances in the detection and management of disease. This article celebrates this breadth of scientific discovery and development by examining the impact that CT has had on the diagnosis, characterization, and management of a sampling of major health challenges, including stroke, vascular diseases, cancer, trauma, acute abdominal pain, and diffuse lung diseases, as related to key technical advances in CT and manifested in Radiology.
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Affiliation(s)
- Geoffrey D Rubin
- From the Duke Clinical Research Institute and Department of Radiology, Duke University School of Medicine, PO Box 17969, 2400 Pratt St, Durham, NC 27715
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Hassan Gamal G. Evaluation of spinal trauma by multi detector computed tomography and magnetic resonance imaging. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2014. [DOI: 10.1016/j.ejrnm.2014.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Rodriguez RM, Baumann BM, Raja AS, Langdorf MI, Anglin D, Bradley RN, Medak AJ, Mower WR, Hendey GW. Diagnostic yields, charges, and radiation dose of chest imaging in blunt trauma evaluations. Acad Emerg Med 2014; 21:644-50. [PMID: 25039548 DOI: 10.1111/acem.12396] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 01/09/2014] [Accepted: 01/13/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Chest radiography (CXR) is the most common imaging in adult blunt trauma patient evaluation. Knowledge of the yields, attendant costs, and radiation doses delivered may guide effective chest imaging utilization. OBJECTIVES The objectives were to determine the diagnostic yields of blunt trauma chest imaging (CXR and chest computed tomography [CT]), to estimate charges and radiation exposure per injury identified, and to delineate assessment points in blunt trauma evaluation at which decision instruments for selective chest imaging would have the greatest effect. METHODS From December 2009 to January 2012, we enrolled patients older than 14 years who received CXR during blunt trauma evaluations at nine U.S. Level I trauma centers in this prospective, observational study. Thoracic injury seen on chest imaging and clinical significance of the injury were defined by a trauma expert panel. Yields of imaging were calculated, as well as mean charges and effective radiation dose (ERD) per injury. RESULTS Of 9,905 enrolled patients, 55.4% had CXR alone, 42.0% had both CXR and CT, and 2.6% had CT alone. The yields for detecting thoracic injury were CXR 8.4% (95% confidence intervals [CIs]) = 7.8% to 8.9%), chest CT 28.8% (95% CI = 27.5% to 30.2%), and chest CT after normal CXR 15.0% (95% CI = 13.9% to 16.2%). The mean charges and ERD (millisievert [mSv]) per injury diagnosis of CXR, chest CT, and chest CT after normal CXR were $3,845 (0.24 mSv), $10,597 (30.9 mSv), and $20,347 (59.3 mSv), respectively. The mean charges and ERD per clinically major thoracic injury diagnosis on chest CT after normal CXR were $203,467 and 593 mSv. CONCLUSIONS Despite greater diagnostic yield, chest CT entails substantially higher charges and radiation dose per injury diagnosed, especially when performed after a normal CXR. Selective chest imaging decision instruments should identify patients who require no chest imaging and patients who may benefit from chest CT after a normal CXR.
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Affiliation(s)
- Robert M. Rodriguez
- Department of Emergency Medicine; The University of California at San Francisco; San Francisco CA
| | - Brigitte M. Baumann
- The Department of Emergency Medicine; Cooper Medical School of Rowan University; Camden NJ
| | - Ali S. Raja
- The Department of Emergency Medicine; Brigham and Women's Hospital/Harvard Medical School; Boston MA
| | - Mark I. Langdorf
- The Department of Emergency Medicine; University of California at Irvine; Irvine CA
| | - Deirdre Anglin
- The Department of Emergency Medicine; Keck School of Medicine-University of Southern California; Los Angeles CA
| | - Richard N. Bradley
- The Department of Emergency Medicine; The University of Texas Health Science Center at Houston; Houston TX
| | - Anthony J. Medak
- The Department of Emergency Medicine; University of California at San Diego School of Medicine; San Diego CA
| | - William R. Mower
- The Department of Emergency Medicine; University of California at Los Angeles; Los Angeles CA
| | - Gregory W. Hendey
- The Department of Emergency Medicine; University of California at San Francisco Fresno Medical Education Program; Fresno CA
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Abstract
STUDY DESIGN Observational, cross-sectional. OBJECTIVE To evaluate cervical spine clearance protocols in level 1 trauma centers in the United States. SUMMARY OF BACKGROUND DATA Cervical spine clearance protocols were developed to prevent missed injuries that could result in neurological deficits. The degree of incorporation of evidence-based guidelines into protocols at trauma centers in the United States is unknown. METHODS Level 1 trauma (n = 191) centers in the United States were contacted. Each available protocol was reviewed for 4 scenarios: clearing the asymptomatic patient, the imaging used in patients not amenable to clinical clearance, the management strategies for patients with persistent neck pain with a negative computed tomographic (CT) scan, and those who are obtunded. RESULTS The response rate was 87%. Cervical spine clearance protocols existed in 57% of the institutions. National Emergency X-Radiography Utilization Study criteria to clear asymptomatic patients were recommended in 89% of protocols. Sixty percent of protocols used CT scans as the first line of imaging. In patients with persistent neck pain with negative CT scan flexion-extension plain radiographs were the most common (30%) next step for clearance. In patients who are obtunded, a CT scan followed by a magnetic resonance imaging was the most common method (31%) of clearance. Eight percent of the protocols recommended dynamic flexion-extension views in patients who are obtunded, which are contraindicated. CONCLUSION Written cervical spine clearance protocols exist in 57% of level 1 trauma centers in the United States. These protocols are highly variable and standardization and utilization of these protocols should be encouraged in all trauma centers to prevent missed injuries and neurological catastrophes. LEVEL OF EVIDENCE 4.
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48
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Raniga SB, Menon V, Al Muzahmi KS, Butt S. MDCT of acute subaxial cervical spine trauma: a mechanism-based approach. Insights Imaging 2014; 5:321-38. [PMID: 24554380 PMCID: PMC4035495 DOI: 10.1007/s13244-014-0311-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 11/22/2013] [Accepted: 01/13/2014] [Indexed: 11/27/2022] Open
Abstract
Injuries to the spinal column are common and road traffic accidents are the commonest cause. Subaxial cervical spine (C3–C7) trauma encompasses a wide spectrum of osseous and ligamentous injuries, in addition to being frequently associated with neurological injury. Multidetector computed tomography (MDCT) is routinely performed to evaluate acute cervical spine trauma, very often as first-line imaging. MDCT provides an insight into the injury morphology, which in turn reflects the mechanics of injury. This article will review the fundamental biomechanical forces underlying the common subaxial spine injuries and resultant injury patterns or “fingerprints” on MDCT. This systematic and focused analysis enables a more accurate and rapid interpretation of cervical spine CT examinations. Mechanical considerations are important in most clinical and surgical decisions to adequately realign the spine, to prevent neurological deterioration and to facilitate appropriate stabilisation. This review will emphasise the variables on CT that affect the surgical management, as well as imaging “pearls” in differentiating “look-alike” lesions with different surgical implications. It will also enable the radiologist in writing clinically relevant CT reports of cervical spine trauma. Teaching Points • Vertebral bodies and disc bear the axial compression forces, while the ligaments bear the distraction forces. • Compressive forces result in fracture and distractive forces result in ligamentous disruption. • Bilateral facet dislocation is the most severe injury of the flexion-distraction spectrum. • Biomechanics-based CT reading will help to rapidly and accurately identify the entire spectrum of injury. • This approach also helps to differentiate look-alike injuries with different clinical implications.
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Affiliation(s)
- Sameer B Raniga
- Division of Radiology, Khoula Hospital, PO BOX 794, Muscat, 117, Oman,
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49
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Emergency CT head and neck imaging: effects of swimmer's position on dose and image quality. Eur Radiol 2014; 24:969-79. [PMID: 24531843 DOI: 10.1007/s00330-014-3105-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 12/20/2013] [Accepted: 01/22/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To compare the effects of different arm positions on dose exposure and image quality (IQ) in cervical spine CT after trauma in different patient groups. METHODS Patients in standard (STD = 126) and in swimmer's position (SWIM = 254) were included. Body mass index (BMI subgroup 1 = underweight to subgroup 4 = obese), anterior-posterior diameter (AP), left-right diameter (LR), area of an ellipse (AoE) and angle between the humeral heads (optimal STD < 3°, optimal SWIM > 10°) were used as grouping criteria. Computed tomography dose index (CTDI) was documented. Two radiologists rated the IQ at three levels (CV1/2, CV4/5, CV7/T1) using a semi-quantitative scale (0 = not diagnostic, 1 = diagnostic with limitations, 2 = diagnostic without limitations). The Mann-Whitney U test correlations of grouping criteria with dose effects and intra-class correlation (ICC) were calculated. RESULTS ICC was 0.87. BMI grouping showed the strongest correlation with dose effects: CTDI of optimal STD versus optimal SWIM positioning was 3.17 mGy versus 2.46 mGy (subgroup 1), 5.47 mGy versus 3.97 mGy (subgroup 2), 7.35 mGy versus 5.96 mGy (subgroup 3) and 8.71 mGy versus 8.18 mGy (subgroup 4). Mean IQ at CV7/T1 was 1.65 versus 1.23 (subgroup 1), 1.27 versus 1.46 (subgroup 2), 1.06 versus 1.46 (subgroup 3), 0.79 versus 1.5 (subgroup 4). CONCLUSION Patients with a BMI > 20 kg/m(2) benefited from both potential dose reduction and improved image quality at the critical cervicothoracic junction when swimmer's position was used. KEY POINTS • BMI is a useful metric for personalized optimization in CT for the c-spine. • Using swimmer's position, patients can benefit from dose reduction. • In some patients a superior image quality can be achieved with swimmer's position. • For swimmer's positioning an angle of more than 10° is optimal.
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50
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Acker SN, Partrick DA, Ross JT, Nadlonek NA, Bronsert M, Bensard DD. Head injury and unclear mechanism of injury: initial hematocrit less than 30 is predictive of abusive head trauma in young children. J Pediatr Surg 2014; 49:338-40. [PMID: 24528981 DOI: 10.1016/j.jpedsurg.2013.10.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 10/09/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Head injury secondary to abusive head trauma (AHT) is a major cause of morbidity and mortality in susceptible young infants and children. Diagnosing AHT remains challenging and is often complicated by a questionable mechanism of injury. Concern of ionizing radiation risk to children undergoing head CT imaging warrants a selective approach. We aimed to evaluate initial findings that could direct further investigation of AHT. METHODS A retrospective review of the trauma databases at a two level one pediatric trauma centers was performed. We reviewed all patients age five years and under with a diagnosis of traumatic brain injury (TBI) from 2002-2011. RESULTS A total of 1129 patients (mean age 1.7 ± 1.7 years; 64% male) with TBI were identified, 429 (38%) of which were the result of AHT. Complete data was available for 921 patients (82%) and were included in statistical evaluation. Forty-eight percent of patients in the AHT group had a hematocrit ≤ 30% on presentation compared to 19% of patients in the non-AHT group. On univariate analysis, a hematocrit of ≤ 30% was predictive of AHT as the cause of injury (P<.0001), as was a platelet count of greater than 400,000 (P<.0001). After controlling for age, sex, ISS, GCS on presentation, need for CPR, and survival to hospital discharge, hematocrit of ≤ 30% and platelets of greater than 400,000 were predictive of AHT as the cause of TBI (P<.05). CONCLUSIONS In the setting of head injury and unclear history of trauma, a hematocrit of ≤ 30% on presentation increases the likelihood of abusive head trauma in children up to the age of 5 years.
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Affiliation(s)
- Shannon N Acker
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - David A Partrick
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - James T Ross
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Nicole A Nadlonek
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Michael Bronsert
- Department of Surgery, Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, CO, USA
| | - Denis D Bensard
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA; Department of Surgery, Denver Health & Hospital Authority, Denver, CO, USA.
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