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Montgomery BK, Orland K, Wilson TA, Chen W, Shirley OC, Segar A, Field AJ, Crawford HA. Examination of the Pediatric Cervical Spine Under Anesthesia. Cureus 2024; 16:e64623. [PMID: 39156372 PMCID: PMC11328828 DOI: 10.7759/cureus.64623] [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] [Accepted: 07/15/2024] [Indexed: 08/20/2024] Open
Abstract
Cervical spine injuries in pediatric patients can have devastating consequences if not properly diagnosed. The standard workup for suspected cervical spine injuries includes cervical X-rays and a high-resolution CT. If suspicion still exists then a cervical MRI is obtained. When the cervical MRI shows ligamentous edema but is unable to determine the integrity of the ligaments then additional workup is needed. Often a flexion and extension lateral cervical X-ray can help determine ligament integrity in the non-sedated cooperative age-appropriate patient. For pediatric patients who are unable to perform the flexion and extension X-ray, we perform a dynamic fluoroscopic examination of the cervical spine under anesthesia. The patient is positioned in the supine position. The C-arm is positioned in the lateral position. The surgeon manually performs distraction, flexion, extension, and translation maneuvers while obtaining live fluoroscopy and assessing for signs of cervical instability. If cervical instability exists then the appropriate definitive treatment can be performed. If the cervical spine is stable then cervical immobilization can be discontinued.
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Affiliation(s)
| | - Keith Orland
- Orthopaedics, Starship Children's Hospital, Auckland, NZL
| | - Troy A Wilson
- Orthopaedics, Starship Children's Hospital, Auckland, NZL
| | - William Chen
- Orthopaedics, Starship Children's Hospital, Auckland, NZL
| | - Otis C Shirley
- Orthopaedics, Starship Children's Hospital, Auckland, NZL
| | - Anand Segar
- Orthopaedics, Starship Children's Hospital, Auckland, NZL
| | - Antony J Field
- Orthopaedics, Starship Children's Hospital, Auckland, NZL
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2
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Sarblah SR, Rachman P, Antwi WK, Anudjo MNK, Botwe BO, Akudjedu TN. Value of MRI in the cervical spine imaging series of trauma patients: A state-of-the-art review. Radiography (Lond) 2024; 30:1001-1013. [PMID: 38692168 DOI: 10.1016/j.radi.2024.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 04/05/2024] [Accepted: 04/18/2024] [Indexed: 05/03/2024]
Abstract
INTRODUCTION Clinical decision protocols for evaluation and assessment of traumatic cervical spine injuries (TCSI) lean more towards the use of CT imaging. Investigation with MRI is therefore considered unnecessary following negative CT findings according to some local protocols. This review aims to explore what benefits MRI may offer in the clinical management of TCSI patients. METHODS A systematic search of the literature was conducted in the following databases: AMED, CINAHL, EMBASE and MEDLINE using defined key terms and synonyms optimised for each database. The eligible articles were subjected to data extraction and thematic synthesis. RESULTS The initial electronic search yielded 2527 articles. Of these, 15 articles remained following the application of a pre-defined inclusion criteria and full-text assessment. Four themes (mechanism of injury, type of patient, injuries detected on MRI, significance of injuries detected on MRI) were developed relating to the usage and value of MRI in the management of CSI. DISCUSSION Our findings indicate that MRI may be very valuable in some situations for the evaluation of TCSI, however, its usage must be cautiously considered on a case-by-case basis in light of additional clinical benefit, patient safety and resource availability following a normal CT scan or in conjunction with CT or projection radiography where appropriate. IMPLICATIONS FOR PRACTICE MRI may serve as a confirmatory test in the management pathway of TCSI based on individual clinical needs. Consideration for key limitations (e.g., patients' cooperation) and accessibility challenges (e.g., cost) against the clinical benefit to the patient must be noted. Development of centre-specific policies from standard trauma imaging protocols may be essential for the timely management of TCSI.
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Affiliation(s)
- S R Sarblah
- Radiology Department, Hereford County Hospital, Wye Valley NHS Foundation Trust, Hereford, UK; Department of Health Sciences, Faculty of Environmental & Life Sciences, Southampton University, UK
| | - P Rachman
- Department of Health Sciences, Faculty of Environmental & Life Sciences, Southampton University, UK
| | - W K Antwi
- Department of Radiography, School of Biomedical and Allied Health Sciences, College of Health Sciences, University of Ghana, Box KB143, Korle Bu, Accra, Ghana
| | - M N K Anudjo
- Institute of Medical Imaging & Visualisation, Department of Medical Science & Public Health, Faculty of Health & Social Sciences, Bournemouth University, Bournemouth, UK; School of Radiology, AECC University College, Bournemouth, UK
| | - B O Botwe
- Department of Radiography, School of Biomedical and Allied Health Sciences, College of Health Sciences, University of Ghana, Box KB143, Korle Bu, Accra, Ghana; Department of Midwifery and Radiography Division School of Health & Psychological Sciences, City, University of London, Northampton Square, London EC1V 0HB, UK
| | - T N Akudjedu
- Institute of Medical Imaging & Visualisation, Department of Medical Science & Public Health, Faculty of Health & Social Sciences, Bournemouth University, Bournemouth, UK.
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3
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Spears SDJ, Abdulle YF, Korovilas D, Torii R, Kalaskar DM, Sharma N. Neck Collar Assessment for People Living With Motor Neuron Disease: Are Current Outcome Measures Suitable? Interact J Med Res 2023; 12:e43274. [PMID: 36917160 PMCID: PMC10131796 DOI: 10.2196/43274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 02/03/2023] [Accepted: 02/06/2023] [Indexed: 03/15/2023] Open
Abstract
A majority of people living with motor neuron disease (MND) experience weakness of the neck and as a result, experience head drop. This exacerbates problems with everyday activities (eating, talking, breathing, etc). Neck collars are often used to support head drop; however, these are typically designed for prehospitalization settings to manage and brace the cervical region of the spine. As a result, it has been recorded that people living with MND often reject these collars for a variety of reasons but most notably because they are too restricting. The current standardized outcome measures (most notably restricting cervical range of motion) used for neck collars are summarized herein along with whether they are suitable for a bespoke neck collar specifically designed for people living with MND.
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Affiliation(s)
- Samuel D J Spears
- Institute of Orthopaedics and Musculoskeletal Science, Division of Surgery and Interventional Sciences, University College London, London, United Kingdom.,National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Yusuf F Abdulle
- National Hospital for Neurology and Neurosurgery, London, United Kingdom.,Department for Clinical and Movement Neurosciences, University College London, London, United Kingdom
| | | | - Ryo Torii
- Department of Mechanical Engineering, University College London, London, United Kingdom
| | - Deepak M Kalaskar
- Institute of Orthopaedics and Musculoskeletal Science, Division of Surgery and Interventional Sciences, University College London, London, United Kingdom
| | - Nikhil Sharma
- National Hospital for Neurology and Neurosurgery, London, United Kingdom.,Department for Clinical and Movement Neurosciences, University College London, London, United Kingdom
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4
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Cabrera JP, Yurac R, Joaquim AF, Guiroy A, Carazzo CA, Zamorano JJ, Valacco M. CT Scan in Subaxial Cervical Facet Injury: Is It Enough for Decision-Making? Global Spine J 2023; 13:344-352. [PMID: 33729870 PMCID: PMC9972275 DOI: 10.1177/2192568221995491] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Cross-sectional survey. OBJECTIVES Assessment of subaxial cervical facet injuries using the AO Spine Subaxial Cervical Spine Injury Classification System is based on CT scan findings. However, additional radiological evaluations are not directly considered. The aim of this study is to determine situations in which spine surgeons request additional radiological exams after a facet fracture. METHODS A survey was sent to AO Spine members from Latin America. The evaluation considered demographic variables, routine use of the Classification, as well as the timepoint at which surgeons requested a cervical MRI, a vascular study, and/ or dynamic radiographs before treatment of facet fractures. RESULTS There was 229 participants, mean age 42.9 ± 10.2 years; 93.4% were men. Orthopedic surgeons 57.6% with 10.7 ± 8.7 years of experience in spine surgery. A total of 86% used the Classification in daily practice. An additional study (MRI/vascular study/and dynamic radiographs) was requested in 53.3%/9.6%/43.7% in F1 facet injuries; 76.0%/20.1%/50.2% in F2; 89.1%/65.1%/28.4% in F3; and 94.8%/66.4%/16.6% in F4. An additional study was frequently required: F1 72.5%, F2 86.9%, F3 94.7%, and F4 96.1%. CONCLUSIONS Spine surgeons generally requested additional radiological evaluations in facet injuries, and MRI was the most common. Dynamic radiographs had a higher prevalence for F1/F2 fractures; vascular studies were more common for F3/F4 especially among surgeons with fewer years of experience. Private hospitals had a lower spine trauma cases/year and requested more MRI and more dynamic radiographs in F1/F2. Neurosurgeons had more vascular studies and dynamic radiographs than orthopedic surgeons in all facet fractures.
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Affiliation(s)
- Juan P. Cabrera
- Department of Neurosurgery, Hospital
Clínico Regional de Concepción, Concepción, Chile,Faculty of Medicine, University of
Concepción, Concepción, Chile,Juan P. Cabrera, Department of Neurosurgery,
Hospital Clínico Regional de Concepción, San Martín 1436, Concepción, Chile.
| | - Ratko Yurac
- Department of Orthopedic and
Traumatology, University del Desarrollo, Santiago, Chile,Spine Unit, Department of Traumatology,
Clínica Alemana, Santiago, Chile
| | - Andrei F. Joaquim
- Department of Neurosurgery, University
of Campinas (UNICAMP), Campinas-SP, Brazil
| | - Alfredo Guiroy
- Spine Unit, Orthopedic Department,
Hospital Español de Mendoza, Mendoza, Argentina
| | - Charles A. Carazzo
- Neurosurgery, University of Passo Fundo,
São Vicente de Paulo Hospital – Passo Fundo – RS, Brazil
| | - Juan J. Zamorano
- Department of Orthopedic and
Traumatology, University del Desarrollo, Santiago, Chile,Spine Unit, Department of Traumatology,
Clínica Alemana, Santiago, Chile
| | - Marcelo Valacco
- Department of Orthopedic and
Traumatology, Hospital Churruca Visca, Buenos Aires, Argentina
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5
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Brannigan JF, Dohle E, Critchley GR, Trivedi R, Laing RJ, Davies BM. Adverse Events Relating to Prolonged Hard Collar Immobilisation: A Systematic Review and Meta-Analysis. Global Spine J 2022; 12:1968-1978. [PMID: 35333123 PMCID: PMC9609519 DOI: 10.1177/21925682221087194] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVE To evaluate systematically the complications of prolonged cervical immobilisation in a hard collar. METHODS Following registration with PROSPERO, a systematic search of electronic databases (MEDLINE, EMBASE) was conducted. Two reviewers independently screened the search results according to pre-determined search criteria. Data was extracted and tabulated. Joanna Briggs Institute checklists were used for assessing the quality of included studies. RESULTS The search identified 773 articles. A total of 25 studies were selected for final inclusion. The results largely comprised a mixture of case reports/series, cohort studies and reviews. The most commonly reported complications were pressure ulcers, dysphagia and increased intracranial pressure. A pressure ulcer pooled prevalence of 7% was calculated. There was insufficient data for quantitative analysis of any other complication. CONCLUSIONS There is significant morbidity from prolonged hard collar immobilisation, even amongst younger patients. Whilst based upon limited and low-quality evidence, these findings, combined with the low-quality evidence for the efficacy of hard collars, highlights a knowledge gap for future research.
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Affiliation(s)
- Jamie F.M. Brannigan
- Division of Neurosurgery,
Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK,School of Clinical Medicine, University of Cambridge, Cambridge, UK,Jamie F.M. Brannigan BA, Division of
Neurosurgery, Department of Clinical Neurosciences, University of Cambridge,
Jesus College, Cambridge CB5 8BL, UK.
| | - Esmee Dohle
- Division of Neurosurgery,
Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK,School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Giles R. Critchley
- Department of Neurosurgery, Brighton and Sussex University
Hospitals National Health Service Trust, Brighton, UK
| | - Rikin Trivedi
- Division of Neurosurgery,
Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Rodney J. Laing
- Division of Neurosurgery,
Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Benjamin M. Davies
- Division of Neurosurgery,
Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK,Myelopathy.org, University of Cambridge, UK
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6
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Chen IW, Li YY, Hung KC, Chang YJ, Chen JY, Lin MC, Wang KF, Lin CM, Huang PW, Sun CK. Comparison of video-stylet and conventional laryngoscope for endotracheal intubation in adults with cervical spine immobilization: A PRISMA-compliant meta-analysis. Medicine (Baltimore) 2022; 101:e30032. [PMID: 35984197 PMCID: PMC9387965 DOI: 10.1097/md.0000000000030032] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Although minimization of cervical spine motion by using a neck collar or manual in-line stabilization is recommended for urgent tracheal intubation (TI) in patients with known or suspected cervical spine injury (CSI), it may worsen glottic visualization. The overall performance of video-stylets during TI in patients with neck immobilization remains unclear. The current meta-analysis aimed at comparing the intubation outcomes of different video-stylets with those of conventional laryngoscopes in patients with cervical immobilization. METHOD The databases of Embase, Medline, and the Cochrane Central Register of Controlled Trials were searched from inception to June 2021 to identify trials comparing intubation outcomes between video-stylets and conventional laryngoscopes. The primary outcome was first-pass success rate, while secondary outcomes included overall success rate, time to intubation, the risk of intubation-associated sore throat, or tissue damage. RESULTS Five randomized controlled trials published between 2007 and 2013 involving 487 participants, all in an operating room setting, were analyzed. The video-stylets investigated included Bonfils intubation fiberscope, Levitan FPS Scope, and Shikani optical stylet. There was no difference in first-pass success rate (risk ratio [RR] =1.08, 95% confidence interval [CI]: 0.89-1.31, P = .46], overall success rate (RR = 1.06, 95% CI: 0.93-1.22, P = .4), intubation time [mean difference = 4.53 seconds, 95% CI: -8.45 to 17.51, P = .49), and risk of tissue damage (RR = 0.46, 95% CI: 0.16-1.3, P = .14) between the 2 groups. The risk of sore throat was lower with video-stylets compared to that with laryngoscopes (RR = 0.45, 95% CI: 0.23-0.9, P = .02). CONCLUSION Our results did not support the use of video-stylets as the first choice for patients with neck immobilization. Further studies are required to verify the efficacy of video-stylets in the nonoperating room setting.
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Affiliation(s)
- I-Wen Chen
- Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan City, Taiwan
| | - Yu-Yu Li
- Department of Anesthesiology, Chi Mei Hospital, ChiaLi, Tainan City, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
- Department of Hospital and Health Care Administration, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, Tainan city, Taiwan
| | - Ying-Jen Chang
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
- Department of Recreation and Health-Care Management, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, Tainan city, Taiwan
| | - Jen-Yin Chen
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Ming-Chung Lin
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Kuei-Fen Wang
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Chien-Ming Lin
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Ping-Wen Huang
- Department of Emergency Medicine, Show Chwan Memorial Hospital, Changhua City, Taiwan
| | - Cheuk-Kwan Sun
- Department of Emergency Medicine, E-Da Hospital, Kaohsiung City, Taiwan
- College of Medicine, I-Shou University, Kaohsiung city, Taiwan
- *Correspondence: Cheuk-Kwan Sun, MD, PhD, Department of Emergency Medicine, E-Da Hospital, No. 1, Yida Road, Jiaosu Village, Yanchao District, Kaohsiung City 82445, Taiwan (e-mail: )
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7
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Culhane J, Parr A, Mercier P. Accuracy of ct evaluation for cervical spine clearance in the ground level fall population - a retrospective cohort study. BMC Emerg Med 2022; 22:106. [PMID: 35690715 PMCID: PMC9188238 DOI: 10.1186/s12873-022-00657-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 05/23/2022] [Indexed: 11/17/2022] Open
Abstract
Background Clinically occult cervical spine (CS) injuries are well described in blunt trauma, however delay in identifying these injuries and clearing the CS can result in morbidity. Our study examines the ground level fall (GLF) population to analyze whether computed tomography (CT) alone can rule out unstable injury in this group with lower force mechanism. Methods This is a single center, retrospective cohort study. All GLF patients in the institutional trauma registry between 6/1/2012 through 12/31/2019 were included. These comprise all trauma patients evaluated in the emergency department with Injury Severity Score (ISS) > 0, including both activations and consults with both clinical and radiological spine evaluation. Patients who could not be cleared by National Emergency X-ray Utilization Study (NEXUS) criteria underwent CT. Patients with CT or clinical suspicion of cord or ligamentous injury underwent MRI. CT occult injuries were identified by MRI and clinical exam, with MRI identifying all unstable injuries. Results Sixty-nine (2.0%) of patients had CS injury without acute CT abnormality. Of these, 11 (0.3%) required surgery and were considered unstable. All patients who required surgery had a neurologic deficit. Negative predictive value (NPV) of CT for unstable CS injury was 99.7%. The combination of acute CT findings and neurologic deficit ruled out unstable CS injury with 100% NPV. Conclusion In the GLF population, CT alone rules out unstable CS injury with high, but not perfect NPV. The combination of absence of acute CT findings and acute neurologic deficits rules out unstable CS injury with 100% NPV. Supplementary information The online version contains supplementary material available at 10.1186/s12873-022-00657-x.
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Affiliation(s)
- John Culhane
- Saint Louis University School of Medicine, Saint Louis, MO, USA. .,Departments of Trauma and Neurosurgery, Saint Louis University, Saint Louis, MO, USA. .,Department of Surgery, Saint Louis University, 1008 Spring Ave, Saint Louis, MO, 63110, USA.
| | - Alan Parr
- Saint Louis University School of Medicine, Saint Louis, MO, USA.,Departments of Trauma and Neurosurgery, Saint Louis University, Saint Louis, MO, USA.,Department of Surgery, Saint Louis University, 1008 Spring Ave, Saint Louis, MO, 63110, USA
| | - Philippe Mercier
- Saint Louis University School of Medicine, Saint Louis, MO, USA.,Departments of Trauma and Neurosurgery, Saint Louis University, Saint Louis, MO, USA.,Department of Neurosurgery, Saint Louis University, 1008 Spring Ave, Saint Louis, MO, 63110, USA
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8
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Chaudhary MJ, Canner JK, Haut ER. The Effect of the Eastern Association for the Surgery of Trauma Guideline on Spinal Magnetic Resonance Imaging Use in Obtunded Adult Blunt Trauma Patients Over Time. J Surg Res 2021; 270:58-67. [PMID: 34638094 DOI: 10.1016/j.jss.2021.08.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/27/2021] [Accepted: 08/27/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Evidence-based guidelines suggest computed tomography without magnetic resonance imaging (MRI) is sufficient to rule out clinically significant cervical spine injury in obtunded adult blunt trauma patients. This study evaluated MRI utilization over time to investigate the impact of the 2015 Eastern Association for the Surgery of Trauma guidelines suggesting cervical collar clearance with computed tomography alone in this population. We hypothesized that MRI utilization would decrease following the guidelines. MATERIALS AND METHODS We performed a retrospective cross-sectional study of the National Trauma Data Bank from 2007 to 2018 using multivariable logistic regression of the likelihood of spinal MRI utilization. Blunt trauma patients 18 y and older with a Glasgow Coma Scale (GCS) of 8 or less, Abbreviated Injury Score head of 4 or greater, intubated for at least 72 h were included. RESULTS The sample consisted of 76,450 patients from 567 trauma centers. Controlling for age, gender, race/ethnicity, insurance status, injury mechanism, Injury Severity Score, GCS, GCS motor, hospital teaching status and trauma center level, patients seen after 2015 had a higher odds ratio (OR) of undergoing spinal MRI relative to those seen before 2015 (OR 1.77, 95% CI 1.49-2.09; P < 0.001). Each year was associated with a significantly increased OR of undergoing spinal MRI compared to the year prior (OR 1.10, 95% CI 1.05-1.15; P < 0.001). CONCLUSIONS Spinal MRI use has been increasing in obtunded adult blunt trauma patients including after the release of the Eastern Association for the Surgery of Trauma guidelines in 2015. Future work should identify whether this is driven by improper MRI utilization and, if so, strategies to promote guideline adherence.
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Affiliation(s)
- Mihir J Chaudhary
- Department of Surgery, University of California San Francisco - East Bay, Oakland, California
| | - Joseph K Canner
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elliott R Haut
- Department of Surgery, Division of Acute Care Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland; The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland; Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
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9
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Sutherland M, Bourne M, McKenney M, Elkbuli A. Utilization of computerized tomography and magnetic resonance imaging for diagnosis of traumatic C-Spine injuries at a level 1 trauma center: A retrospective Cohort analysis. Ann Med Surg (Lond) 2021; 68:102566. [PMID: 34336197 PMCID: PMC8318846 DOI: 10.1016/j.amsu.2021.102566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 10/26/2022] Open
Abstract
Background Computerized tomography (CT) is a common imaging modality for trauma patients, but there is debate regarding the role of magnetic resonance imaging (MRI) in cervical (C)-spine clearance. We aim to investigate the utilization of CT and MRI imaging in traumatic C-spine clearance and associated outcomes on patients who undergo both imaging modalities. Methods A 4-year retrospective review was performed to evaluate the trauma patient imaging algorithm at our institution. The algorithm required CT as a screening examination for traumatic injury patients who are unexaminable because of distracting injury, altered mental status, an abnormal neurological examination, and/or central neck pain. MRI was performed after CT in patients with C-spine injuries identified on CT, those who remained unexaminable, had an abnormal neurological examination, or experienced persistent central neck tenderness. Univariate analyses and adjusted multivariate logistic regression were performed with significance defined as p < 0.05. Results 805 patients were analyzed. Compared to MRI, CT had a sensitivity of 50.2%, specificity of 76.6%, positive predictive value of 69.7%, and negative predictive value of 59.0% in detecting C-spine injuries. CT and MRI differed significantly in their ability to detect C-spine soft tissue injuries and C1 vertebral fractures (p < 0.05). Conclusions MRI is more capable of detecting soft tissue injuries whereas CT is superior in detecting vertebral fractures. Our findings support the need to utilize CT and MRI in conjunction to detect both bony and soft tissue C-spine injuries in traumatically injured patients, who are either unexaminable, have an abnormal neurologic examination, or ongoing central neck tenderness.
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Affiliation(s)
- Mason Sutherland
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA
| | - Mitchell Bourne
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA.,Department of Surgery, University of South Florida, Tampa, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA
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10
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Thompson L, Shaw G, Bates C, Hawkins C, McClelland G, McMeekin P. To collar or not to collar. Views of pre-hospital emergency care providers on immobilisation without cervical collars: a focus group study. Br Paramed J 2021; 6:38-45. [PMID: 34335099 PMCID: PMC8312363 DOI: 10.29045/14784726.2021.6.6.1.38] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Spinal cord injury (SCI) is a rare event, with high numbers of patients unnecessarily immobilised with no potential benefit based on limited evidence from the 1950s and 1960s. Contemporary opinion now challenges the notion that traditional immobilisation prevents movement and protects the spine. Current literature suggests that these methods which include semi-rigid collars can potentially cause more movement of the spine and harm the patient. The purpose of this study was to explore the views and perspectives of pre-hospital care providers on immobilising patients without the use of a semi-rigid collar. METHODS Focus groups were used to allow individuals to discuss and comment on a new method of immobilisation which omits the semi-rigid collar and to capture the thoughts, feelings and experiences of participants. Thematic analysis of the coded transcriptions was used to identify emerging themes. RESULTS Three focus groups were conducted with 15 participants in each. Participants were all exposed to patients sustaining trauma within their professional roles. Six intertwined themes emerged from the analysis: communication, conflict, education/training, empowerment, risk and the patient. Woven between these themes are the complex interactions that bring together the inter-professional relationships with other emergency services and hospital staff, the patient, the public and pre-hospital care providers. DISCUSSION Existing immobilisation practices are being challenged, with clinicians empowered to tailor practice to meet specific patient needs. There is limited empirical evidence to support current immobilisation practices. Contemporary literature suggests current practices may potentially cause harm. New pragmatic immobilisation practices are gradually being adopted by some pre-hospital care providers. CONCLUSION This study explored the perspectives of pre-hospital care providers on immobilising patients without the use of a semi-rigid collar for potential SCI. The consensus of the participants supports a pragmatic approach to managing potential SCI that provides safe, high-quality patient-centred care.
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Affiliation(s)
- Lee Thompson
- North East Ambulance Service NHS Foundation Trust ORCID iD: http://orcid.org/0000-0002-0820-1662
| | - Gary Shaw
- North East Ambulance Service NHS Foundation Trust
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11
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Fennessy J, Wick J, Scott F, Roberto R, Javidan Y, Klineberg E. The Utility of Magnetic Resonance Imaging for Detecting Unstable Cervical Spine Injuries in the Neurologically Intact Traumatized Patient Following Negative Computed Tomography Imaging. Int J Spine Surg 2021; 14:901-907. [PMID: 33560249 DOI: 10.14444/7138] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Neurologically intact blunt trauma patients with persistent neck pain and negative computed tomography (CT) imaging frequently undergo magnetic resonance imaging (MRI) for evaluation of occult cervical spine injury. There is a paucity of data to support or refute this practice. This study was therefore performed to evaluate the utility of cervical spine MRI in neurologically intact blunt trauma patients with negative CT imaging. METHODS A retrospective review was performed of all neurologically intact blunt trauma patients presenting to a level 1 trauma center from 2005 to 2015 with persistent neck pain and negative CT imaging. The proportion of patients with positive MRI findings, subsequent treatment, and time required to obtain MRI results was evaluated. RESULTS Of 223 patients meeting inclusion criteria, 11 had positive MRI findings; however, no patients were found to have unstable injuries requiring surgical treatment. The process for a complete evaluation of unstable cervical spine injury from the time of obtaining a CT scan was 19 hours and 43 minutes. CONCLUSIONS Eleven patients had positive MRI findings, yet these findings did not alter treatment. In contrast, the time required to obtain MRI results may substantially delay patient care. LEVEL OF EVIDENCE IV (retrospective case series) CLINICAL RELEVANCE: Our results demonstrate that MRI has limited utility in neurologically intact blunt trauma patients with negative CT imaging.
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Affiliation(s)
| | - Joseph Wick
- University of California, Davis, Sacramento, California
| | - Fiona Scott
- University of California, Davis, Sacramento, California
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Buchanan FR, Wang VY, Amadio JP, Ortega-Barnett JR, Brown LH, Teixeira PG, Aydelotte JD, Leede E, Ali S, Brown CVR. Does preoperative magnetic resonance imaging alter the surgical plan in patients with acute traumatic cervical spinal cord injury? J Trauma Acute Care Surg 2021; 90:157-162. [PMID: 33009342 DOI: 10.1097/ta.0000000000002962] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Whether magnetic resonance imaging (MRI) adds value to surgical planning for patients with acute traumatic cervical spinal cord injury (ATCSCI) remains controversial. In this study, we compared surgeons' operative planning decisions with and without preoperative MRI. We had two hypotheses: (1) the surgical plan for ATCSCI would not change substantially after the MRI and (2) intersurgeon agreement on the surgical plan would also not change substantially after the MRI. METHODS We performed a vignette-based survey study that included a retrospective review of all adult trauma patients who presented to our American College of Surgeons-verified level 1 trauma center from 2010 to 2019 with signs of acute quadriplegia and underwent computed tomography (CT), MRI, and subsequent cervical spine surgery within 48 hours of admission. We abstracted patient demographics, admission physiology, and injury details. Patient clinical scenarios were presented to three spine surgeons, first with only the CT and then, a minimum of 2 weeks later, with both the CT and MRI. At each presentation, the surgeons identified their surgical plan, which included timing (none, <8, <24, >24 hours), approach (anterior, posterior, circumferential), and targeted vertebral levels. The outcomes were change in surgical plan and intersurgeon agreement. We used Fleiss' kappa (κ) to measure intersurgeon agreement. RESULTS Twenty-nine patients met the criteria and were included. Ninety-three percent of the surgical plans were changed after the MRI. Intersurgeon agreement was "slight" to "fair" both before the MRI (timing, κ = 0.22; approach, κ = 0.35; levels, κ = 0.13) and after the MRI (timing, κ = 0.06; approach, κ = 0.27; levels, κ = 0.10). CONCLUSION Surgical plans for ATCSCI changed substantially when the MRI was presented in addition to the CT; however, intersurgeon agreement regarding the surgical plan was low and not improved by the addition of the MRI. LEVEL OF EVIDENCE Diagnostic, level II.
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Affiliation(s)
- Frank R Buchanan
- From the Department of Surgery and Perioperative Care (F.R.B., V.Y.W., J.P.A., J.R.O.-B., L.H.B., P.G.T., J.D.A., E.L., S.A.), Dell Medical School, and Trauma Services, Dell Seton Medical Center (C.V.R.B.), University of Texas at Austin, Austin, Texas
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13
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Cervical Spine Clearance in Trauma Patients with an Unreliable Physical Examination. World J Surg 2020; 44:1113-1120. [PMID: 31802188 DOI: 10.1007/s00268-019-05307-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND The objective of this study was to describe and compare the timing of cervical spine clearance in trauma patients with an unreliable physical examination. METHODS We prospectively included adult trauma patients admitted with a cervical collar and an unreliable clinical examination (as defined by the NEXUS criteria) at two level 1 trauma centers: one in the USA (US) and one in Denmark (DK). We excluded patients with cervical spine injuries requiring a collar or surgery as treatment and patients with a collar placed after hospital arrival. The primary outcome was time from emergency department (ED) arrival to collar removal. Secondary outcomes included time to CT of the cervical spine (CTCS). At the US trauma center, an institutional protocol allowing cervical spine clearance exclusively by CTCS was in place. At the Danish trauma center, cervical spine clearance was based on a clinical evaluation by an orthopedic surgeon, usually after CTCS. RESULTS A total of 113 patients were included (US: n = 56; DK: n = 57). The median age was 47 years, and 68% were males. The main reasons for an unreliable physical examination were a Glasgow Coma Scale score below 14 (35%), distracting injuries (26%), cervical spine tenderness (13%) and intoxication (13%). The injury severity score at the US trauma center was higher than at the DK trauma center (median: 17 vs. 11, p = 0.03). Both time to CTCS (median: 41 vs. 18 min, p < 0.0001) and time to collar removal (median: 1042 vs. 49 min, p < 0.0001) were significantly greater at the US trauma center. CONCLUSIONS Time to collar removal was significantly greater in a trauma center utilizing a cervical spine clearance protocol based on CTCS. As patients may develop complications related to the collar, future studies should clarify how early removal can be implemented without increasing the risk of morbidity.
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Castro-Marin F, Gaither JB, Rice AD, N Blust R, Chikani V, Vossbrink A, Bobrow BJ. Prehospital Protocols Reducing Long Spinal Board Use Are Not Associated with a Change in Incidence of Spinal Cord Injury. PREHOSP EMERG CARE 2020; 24:401-410. [PMID: 31348691 DOI: 10.1080/10903127.2019.1645923] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction: Many emergency medical services (EMS) agencies have de-emphasized or eliminated the use of long spinal boards (LSB) for patients with possible spinal injury. We sought to determine if implementation of spinal motion restriction (SMR) protocols, which reduce LSB use, was associated with an increase in spinal cord injury (SCI). Methods: This retrospective observational study includes EMS encounters from January 1, 2013 to December 31, 2015 submitted by SMR-adopting ground-based agencies to a state EMS database with hospital discharge data. Encounters were excluded if SMR implementation date was unknown, occurred during a 3-month run-in period, or were duplicates. Study samples include patients with traumatic injury (TI), possible spinal trauma (P-ST), and verified spinal trauma (V-ST) using hospital discharge ICD-9/10 diagnosis codes. The incidence of SCI before and after implementation of SMR was compared using Chi-squared and logistic regression. Results: From 1,005,978 linked encounters, 104,315 unique encounters with traumatic injury and known SMR implementation date were identified with 51,199 cases of P-ST and 5,178 V-ST cases. The incidence of SCI in the pre-SMR and post-SMR interval for each group was: TI, 0.20% vs. 0.22% (p = 0.390); P-ST, 0.40% vs. 0.45% (p = 0.436); and V-ST, 4.04% vs. 4.37% (p = 0.561). Age and injury severity adjusted odds ratio of SCI in the highest risk cohort of patients with V-ST was 1.097 after SMR implementation (95% CI 0.818-1.472). Conclusion: In this limited study, no change in the incidence of SCI was identified following implementation of SMR protocols. Prospective evaluation of this question is necessary to evaluate the safety of SMR protocols.
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Wu X, Malhotra A, Geng B, Kalra VB, Abbed K, Forman HP, Sanelli P. Cost-effectiveness of Magnetic Resonance Imaging in Cervical Clearance of Obtunded Blunt Trauma After a Normal Computed Tomographic Finding. JAMA Surg 2019. [PMID: 29541757 DOI: 10.1001/jamasurg.2018.0099] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance Magnetic resonance imaging (MRI) continues to be performed for cervical clearance of obtunded blunt trauma, despite poor evidence regarding its utility after a normal computed tomographic (CT) finding. Objective To evaluate the utility and cost-effectiveness of MRI vs no follow-up after a normal cervical CT finding in patients with obtunded blunt trauma. Design, Setting and Participants This cost-effectiveness analysis evaluated an average patient aged 40 years with blunt trauma from an institutional practice. The analysis used a Markov decision model over a lifetime horizon from a societal perspective with variables from systematic reviews and meta-analyses and reimbursement rates from the Centers for Medicare & Medicaid Services, National Spinal Cord Injury Database, and other large published studies. Data were collected from the most recent literature available. Interventions No follow-up vs MRI follow-up after a normal cervical CT finding. Results In the base case of a 40-year-old patient, the cost of MRI follow-up was $14 185 with a health benefit of 24.02 quality-adjusted life-years (QALY); the cost of no follow-up was $1059 with a health benefit of 24.11 QALY, and thus no follow-up was the dominant strategy. Probabilistic sensitivity analysis showed no follow-up to be the better strategy in all 10 000 iterations. No follow-up was the better strategy when the negative predictive value of the initial CT was relatively high (>98%) or the risk of an injury treated with a cervical collar turning into a permanent neurologic deficit was higher than 25% or when the risk of a missed injury turning into a neurologic deficit was less than 58%. The sensitivity and specificity of MRI were varied simultaneously in a 2-way sensitivity analysis, and no follow-up remained the optimal strategy. Conclusions and Relevance Magnetic resonance imaging had a lower health benefit and a higher cost compared with no follow-up after a normal CT finding in patients with obtunded blunt trauma to the cervical spine, a finding that does not support the use of MRI in this group of patients. The conclusion is robust in sensitivity analyses varying key variables in the model. More literature on these key variables is needed before MRI can be considered to be beneficial in the evaluation of obtunded blunt trauma.
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Affiliation(s)
- Xiao Wu
- currently a medical student at Yale School of Medicine, New Haven, Connecticut
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Bertie Geng
- currently a medical student at Yale School of Medicine, New Haven, Connecticut
| | - Vivek B Kalra
- Department of Radiology, Orlando Health, Orlando, Florida
| | - Khalid Abbed
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | - Howard P Forman
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut.,Department of Economics, Yale School of Medicine, New Haven, Connecticut.,Department of Management, Yale School of Medicine, New Haven, Connecticut.,Department of Public Health, Yale School of Medicine, New Haven, Connecticut
| | - Pina Sanelli
- Department of Radiology, Northwell Health, Manhasset, New York
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Albaghdadi A, Leeds IL, Florecki KL, Canner JK, Schneider EB, Sakran JV, Haut ER. Variation in the use of MRI for cervical spine clearance: an opportunity to simultaneously improve clinical care and decrease cost. Trauma Surg Acute Care Open 2019; 4:e000336. [PMID: 31392284 PMCID: PMC6660802 DOI: 10.1136/tsaco-2019-000336] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 06/07/2019] [Indexed: 12/03/2022] Open
Abstract
Background For years, controversy has existed about the ideal approach for cervical spine clearance in obtunded, blunt trauma patients. However, recent national guidelines suggest that MRI is not necessary for collar clearance in these patients. The purpose of this study was to identify the extent of national variation in the use of MRI and assess patient-specific and hospital-specific factors associated with the practice. Methods We performed a retrospective review of the National Trauma Data Bank from 2007 to 2012. We included blunt trauma patients aged ≥18 years, admitted to level 1 or 2 trauma centers (TCs), with a Glasgow Coma Scale <8, Abbreviated Injury Scale >3 for the head and mechanically ventilated for more than 72 hours. Multilevel modeling was used to identify patient-level and hospital-level factors associated with spine MRI use. Results 32 125 obtunded, blunt trauma patients treated at 395 unique TCs met our inclusion criteria. The mean proportion of patients who received MRI over the entire sample was 9.9%. The proportions of patients at each hospital who received a spine MRI ranged from 0.5% to 68.7%. Younger patients, with injuries from motor vehicle collisions and pedestrian injuries, were more likely to receive MRI. When controlling for other variables, Injury Severity Score (ISS) was not associated with MRI use. Hospitals in the Northeast, level 1 TCs and non-teaching hospitals were more likely to obtain MRIs in this patient population. Conclusion After controlling for patient-level characteristics, variation remained in MRI use based on geography, trauma center level and teaching status. This evidence suggests that current national guidelines limiting the use of MRI for cervical spine evaluation following blunt trauma are not being followed consistently. This may be due to physicians not being up to date with best practice care, unavailability of locally adopted protocols in institutions or lack of consensus among clinical providers. Level of evidence Prognostic and epidemiological, level III.
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Affiliation(s)
- Alia Albaghdadi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ira L Leeds
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Joseph K Canner
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eric B Schneider
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joseph V Sakran
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elliott R Haut
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Deacon C, Craxford S, Ollivere BJ. Evaluating the cervical spine in confused or unconscious adults after blunt trauma. Br J Hosp Med (Lond) 2019; 80:317-319. [PMID: 31180783 DOI: 10.12968/hmed.2019.80.6.317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Potential injury to the cervical spine should be considered in all patients who have suffered blunt trauma. Early spinal immobilization is required to minimize the risk of secondary spinal cord injury. However, prolonged immobilization is associated with its own morbidity. Clinical evaluation of the cervical spine in confused or unconscious adult trauma patients is challenging, and imaging is required to safely 'clear' the cervical spine. Despite the existence of national guidelines, significant variations in practice exist. This article summarizes the evidence for the initial stabilization of the cervical spine in adult trauma patients. It reviews the imaging modalities available and the criteria for discontinuation of cervical spine immobilization.
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Affiliation(s)
- Christopher Deacon
- FY2 Doctor, Academic Orthopaedics, Trauma and Sports Medicine, Division of Rheumatology, Orthopaedics, and Dermatology, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH
| | - Simon Craxford
- Research Fellow, Academic Orthopaedics, Trauma and Sports Medicine, Division of Rheumatology, Orthopaedics, and Dermatology, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham
| | - Benjamin J Ollivere
- Clinical Associate Professor for Trauma, Academic Orthopaedics, Trauma and Sports Medicine, Division of Rheumatology, Orthopaedics, and Dermatology, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham
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Veiga JRS, Mitchell K. Cervical spine clearance in the adult obtunded blunt trauma patient: A systematic review. Intensive Crit Care Nurs 2018; 51:57-63. [PMID: 30509691 DOI: 10.1016/j.iccn.2018.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 10/02/2018] [Accepted: 11/05/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND A missed cervical spinal injury could have devastating consequences. Patients with a suspected cervical spinal injury are kept in rigid collars for cervical immobilisation. Prolonged collar use has important clinical implications. A well-defined guideline related to the removal of cervical collars from adult obtunded blunt trauma patients has not been developed. AIM We sought to determine if Magnetic Resonance Imaging offered a definitive benefit over Computer Tomography with respect to patient management. METHOD We searched Ovid Online, EBSCO, NICE Evidence Journals, Medline, PubMED, BNI, CINAHL and Google Scholar as well as the grey literature. Data extraction and synthesis were performed on studies that compared the radiologic findings and clinical outcomes of Computer Tomography scan and Magnetic Resonance Imaging in this patient group. RESULTS There is evidence that supports the safe discontinuation of cervical collar use after a negative multidetector Computer Tomography scan result alone. Magnetic Resonance Imaging may detect a significant number of ligamentous injuries, but such injuries are rarely of clinical significance because they rarely alter clinical management. Its use should be limited to specific circumstances. CONCLUSION It is important for institutions to re-examine the latest evidence regarding cervical spinal clearance in order to update their guidelines.
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Affiliation(s)
| | - Kay Mitchell
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK; Critical Care Research Group, Southampton NIHR Biomedical Research Centre, University Hospital Southampton, Southampton, UK
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Cervical spinal cord injury after blunt assault: Just a pain in the neck? Am J Surg 2018; 217:648-652. [PMID: 30665737 DOI: 10.1016/j.amjsurg.2018.06.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 06/14/2018] [Accepted: 06/21/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND We aimed to determine the incidence, risk factors, and outcomes of cervical spinal cord injury (CSCI) after blunt assault. METHODS The ACS National Trauma Data Bank (NTDB) 2012 Research Data Set was used to identify victims of blunt assault using the ICD-9 E-codes 960.0, 968.2, 973. ICD-9 codes 805.00, 839.00, 806.00, 952.00 identified cervical vertebral fractures/dislocations and CSCI. Multivariable analyses were performed to identify independent predictors of CSCI. RESULTS 14,835 (2%) out of 833,311 NTDB cases were blunt assault victims and thus included. 217 (1%) had cervical vertebral fracture/dislocation without CSCI; 57 (0.4%) had CSCI. Age ≥55 years was independently predictive of CSCI; assault by striking/thrown object, facial fracture, and intracranial injury predicted the absence of CSCI. 25 (0.02%) patients with CSCI underwent cervical spinal fusion. CONCLUSIONS CSCI is rare after blunt assault. While the odds of CSCI increase with age, facial fracture or intracranial injury predicts the absence of CSCI. SUMMARY The incidence, risk factors, and outcomes of cervical spinal cord injury (CSCI) after blunt assault was investigated. 14,835 blunt assault victims were identified; 217 had cervical vertebral fracture/dislocation without CSCI; 57 had CSCI. Age ≥55 years was found to independently predict CSCI, while assault by striking/thrown object, facial fracture, and intracranial injury predicted the absence of CSCI.
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21
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Chilvers G, Porter K, Choudhary S. Cervical spine clearance in adults following blunt trauma: a national survey across major trauma centres in England. Clin Radiol 2018; 73:410.e1-410.e8. [DOI: 10.1016/j.crad.2017.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 11/02/2017] [Indexed: 10/18/2022]
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Mi J, Sun XJ, Zhang K, Zhao CQ, Zhao J. Prediction of MRI findings including disc injury and posterior ligamentous complex injury in neurologically intact thoracolumbar burst fractures by the parameters of vertebral body damage on CT scan. Injury 2018; 49:272-278. [PMID: 29290375 DOI: 10.1016/j.injury.2017.12.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 12/04/2017] [Accepted: 12/12/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To formulate radiological indexes based on CT for further MRI examination to detect posterior ligamentous complex injury (PLC) or disc injury in thoracolumbar burst fractures without neurological deficit in the emergent setting. MATERIALS AND METHODS Patients with a single thoracolumbar burst fracture and no neurological deficit were included into this study. Radiological indexes on CT included canal compromise (CC), anterior and posterior vertebral height ratio (PVH and AVH ratio), local kyphosis (LK) and regional kyphosis (RK). PLC and disc injury were assessed on MRI. Statistical analysis was performed to identify the predictive power for radiological indexes for any MRI findings either or both disc and PLC injury. RESULTS Eighty-four patients were included in this study. According to MRI, patients with no PLC and disc injury were allocated into MRI finding negative group, others were defined as positive group. There was no significant difference in AVH ratio, PVH ratio and RK between these two groups. The CC and LK were significant higher in positive group than that in negative group (p < 0.001).The areas under receiver operating characteristic curve were 0.826 and 0.893 for CC and LK respectively and without significant difference. The best thresholds for CC and LK were 0.19 (sensitivity: 69.4%; specificity: 87.5%) and 14.00° (sensitivity: 83.3%; specificity: 83.3%), respectively. CONCLUSION The presence of CC > 0.19 and/or LK > 14.00° on CT scan can predict MRI findings including PLC and disc injury. These thresholds may be the guideline for MRI examination in patients with neurologically intact thoracolumbar burst fracture in the emergent condition.
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Affiliation(s)
- Jie Mi
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China
| | - Xiao-Jiang Sun
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China
| | - Kai Zhang
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China
| | - Chang-Qing Zhao
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China
| | - Jie Zhao
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China.
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Lau BPH, Hey HWD, Lau ETC, Nee PY, Tan KA, Tan WT. The utility of magnetic resonance imaging in addition to computed tomography scans in the evaluation of cervical spine injuries: a study of obtunded blunt trauma patients. 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 2017; 27:1028-1033. [PMID: 28993912 DOI: 10.1007/s00586-017-5317-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 08/03/2017] [Accepted: 09/26/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Bernard Puang Huh Lau
- University Orthopaedic, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Hospital, 1E Kent Ridge Road, NUHS Tower Block Level 11, Singapore, 119228, Singapore
| | - Hwee Weng Dennis Hey
- University Orthopaedic, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Hospital, 1E Kent Ridge Road, NUHS Tower Block Level 11, Singapore, 119228, Singapore.
| | - Eugene Tze-Chun Lau
- University Orthopaedic, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Hospital, 1E Kent Ridge Road, NUHS Tower Block Level 11, Singapore, 119228, Singapore
| | - Pei Yi Nee
- Division of Family Medicine, National University Hospital, Singapore, Singapore
| | - Kimberly-Anne Tan
- University Orthopaedic, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Hospital, 1E Kent Ridge Road, NUHS Tower Block Level 11, Singapore, 119228, Singapore
| | - Wah Tze Tan
- Department of Anaesthesia, Ng Teng Fong General Hospital, Singapore, Singapore
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Wu X, Malhotra A, Geng B, Liu R, Abbed K, Forman HP, Sanelli P. Cost-effectiveness of Magnetic Resonance Imaging in Cervical Spine Clearance of Neurologically Intact Patients With Blunt Trauma. Ann Emerg Med 2017; 71:64-73. [PMID: 28826754 DOI: 10.1016/j.annemergmed.2017.07.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 05/05/2017] [Accepted: 07/03/2017] [Indexed: 02/07/2023]
Abstract
STUDY OBJECTIVE Use of magnetic resonance imaging (MRI) for cervical clearance after a negative cervical computed tomography (CT) scan result in alert patients with blunt trauma who are neurologically intact is not infrequent, despite poor evidence in regard to its utility. The objective of this study is to evaluate the utility and cost-effectiveness of using MRI versus no follow-up in this patient population. METHODS A modeling-based decision analysis was performed during the lifetime of a 40-year-old individual from a societal perspective. The 2 strategies compared were no follow-up and MRI. A Markov model with a 3% discount rate was used with parameters from the literature. Base cases and probabilistic and sensitivity analyses were performed to assess the cost-effectiveness of the strategies. RESULTS The cost of MRI follow-up was $11,477, with a health benefit of 24.03 quality-adjusted life-years; the cost of no follow-up was $6,432, with a health benefit of 24.08 quality-adjusted life-years. No follow-up was the dominant strategy, with a lower cost and a higher utility. Probabilistic sensitivity analysis showed no follow-up to be the better strategy in all 10,000 iterations. No follow-up was the better strategy irrespective of the negative predictive value of initial CT result, and it remained the better strategy when the incidence of missed unstable injury resulting in permanent neurologic deficits was less than 64.2% and the incidence of patients immobilized with a hard collar who still received cord injury was greater than 19.7%. Multiple 3-way sensitivity analyses were performed. CONCLUSION MRI is not cost-effective for further evaluation of unstable injury in neurologically intact patients with blunt trauma after a negative cervical spine CT result.
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Affiliation(s)
- Xiao Wu
- Yale School of Medicine, New Haven, CT
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT.
| | | | - Renu Liu
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT
| | - Khalid Abbed
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT
| | - Howard P Forman
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT; Departments of Economics, Management, and Public Health, Yale School of Medicine, New Haven, CT
| | - Pina Sanelli
- Department of Radiology, Northwell Health, Long Island, NY
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Cost-effectiveness of cervical spine clearance interventions with litigation and long-term-care implications in obtunded adult patients following blunt injury. J Trauma Acute Care Surg 2017; 81:897-904. [PMID: 27602907 DOI: 10.1097/ta.0000000000001243] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Recent guidelines from the Eastern Association for the Surgery of Trauma conditionally recommend cervical collar removal after a negative cervical computed tomography in obtunded adult blunt trauma patients. Although the rates of missed injury are extremely low, the impact of chronic care costs and litigation upon decision making remains unclear. We hypothesize that the cost-effectiveness of strategies that include additional imaging may contradict current guidelines. METHODS A cost-effectiveness analysis was performed for a base-case 40-year-old, obtunded man with a negative computed tomography. Strategies compared included adjunct imaging with cervical magnetic resonance imaging (MRI), collar maintenance for 6 weeks, or removal. Data on the probability for long-term collar complications, spine injury, imaging costs, complications associated with MRI, acute and chronic care, and litigation were obtained from published and Medicare data. Outcomes were expressed as 2014 US dollars and quality-adjusted life-years. RESULTS Collar removal was more effective and less costly than collar use or MRI (19.99 vs. 19.35 vs. 18.70 quality-adjusted life-years; $675,359 vs. $685,546 vs. $685,848) in the base-case analysis. When the probability of missed cervical injury was greater than 0.04 adjunct imaging with MRI dominated, however, collar removal remained cost-effective until the probability of missed injury exceeded 0.113 at which point collar removal exceeded the $50,000 threshold. Collar removal remained the most cost-effective approach until the probability of complications from collar use was reduced to less than 0.009, at which point collar maintenance became the most cost-effective strategy. Early collar removal dominates all strategies until the risk of complications from MRI positioning is reduced to 0.03 and remained cost-effective even when the probability of complication was reduced to 0. CONCLUSION Early collar removal in obtunded adult blunt trauma patients appears to be the most effective and least costly strategy for cervical clearance based on the current literature available. LEVEL OF EVIDENCE Economic evaluation, level III; therapeutic study, level IV.
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Stanton D, Hardcastle T, Muhlbauer D, van Zyl D. Cervical collars and immobilisation: A South African best practice recommendation. Afr J Emerg Med 2017; 7:4-8. [PMID: 30456099 PMCID: PMC6234176 DOI: 10.1016/j.afjem.2017.01.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 11/22/2016] [Accepted: 01/10/2017] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The consequences of spinal injury as a result of trauma can be devastating. Spinal immobilisation using hard trauma boards and rigid cervical collars has traditionally been the standard response to suspected spinal injury patients even though the risk may be extremely low. Recently, adverse events due to the method of immobilisation have challenged the need for motion restriction in all trauma patients. International guidelines have been published for protection of the spine during transport and this article brings those guidelines into the South African context. RECOMMENDATIONS Trauma patients need to be properly assessed using both an approved list of high and low risk factors, as well as a thorough examination. They should then be managed accordingly. Internationally validated assessment strategies have been developed, and should be used as part of the patient assessment. The method of motion restriction should be selected to suit the situation. The use of a vacuum mattress is the preferable technique, with the use of a trauma board being the least desirable. CONCLUSION The need for motion restriction in suspected spinal injury should be properly evaluated and appropriate action taken. Not all trauma patients require spinal motion restriction.
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Affiliation(s)
- D. Stanton
- Netcare Education, Faculty of Emergency and Critical Care, South Africa
| | - T. Hardcastle
- University of Kwazulu Natal, Trauma Surgery Training Unit, Inkosi Albert Luthuli Central Hospital Trauma Service and Trauma ICU, South Africa
| | - D. Muhlbauer
- Department of Emergency Medical Care and Rescue, Durban University of Technology, South Africa
| | - D. van Zyl
- Life Flora Hospital Advanced Life Support Unit, South Africa
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Cervical Spinal Cord Injury without Computed Tomography Evidence of Trauma in Adults: Magnetic Resonance Imaging Prognostic Factors. World Neurosurg 2017; 99:192-199. [DOI: 10.1016/j.wneu.2016.12.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 12/01/2016] [Accepted: 12/02/2016] [Indexed: 11/18/2022]
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Moore JM, Hall J, Ditchfield M, Xenos C, Danks A. Utility of plain radiographs and MRI in cervical spine clearance in symptomatic non-obtunded pediatric patients without high-impact trauma. Childs Nerv Syst 2017; 33:249-258. [PMID: 27924366 DOI: 10.1007/s00381-016-3273-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 10/07/2016] [Indexed: 12/19/2022]
Abstract
PURPOSE The optimal imaging modality for evaluating cervical spine trauma and optimizing management in the pediatric population is controversial. In pediatric populations, there are no well-established guidelines for cervical spine trauma evaluation and treatment. Currently, there is virtually no literature regarding imaging and management of symptomatic pediatric patients who present with cervical spine trauma without high-impact mechanism. This study aims to establish an optimal imaging strategy for this subgroup of trauma patients. METHODS We performed a retrospective review of pediatric patients (aged below 18 years) who were admitted to Monash Medical Centre, Melbourne, Australia between July 2011 and June 2015, who did not suffer a high-impact trauma but were symptomatic for cervical spine injury following cervical trauma. Imaging and management strategies were reviewed and results compared. RESULTS Forty-seven pediatric patients were identified who met the inclusion criteria. Of these patients, 46 underwent cervical spine series (CSS) plain radiograph imaging. Thirty-four cases underwent magnetic resonance imaging (MRI) and 9 patients underwent CT. MRI was able to detect 4 cases of ligamentous injury, which were not seen in CSS imaging and was able to facilitate cervical spine clearance in a further two patients whose CSS radiographs were abnormal. CONCLUSION In this study, MRI has a greater sensitivity and specificity when compared to CSS radiography in a symptomatic pediatric low-impact trauma population. Our data call in to question the routine use of CSS radiographs in children.
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Affiliation(s)
- Justin M Moore
- Department of Neurosurgery, Monash Medical Centre, 246 Clayton Rd, Melbourne, Clayton, VIC 3168, Australia.
| | - Jonathan Hall
- Department of Neurosurgery, Monash Medical Centre, 246 Clayton Rd, Melbourne, Clayton, VIC 3168, Australia
| | - Michael Ditchfield
- Department of Pediatric Imaging, Monash Medical Centre, Melbourne, Australia
| | - Christopher Xenos
- Department of Neurosurgery, Monash Medical Centre, 246 Clayton Rd, Melbourne, Clayton, VIC 3168, Australia
| | - Andrew Danks
- Department of Neurosurgery, Monash Medical Centre, 246 Clayton Rd, Melbourne, Clayton, VIC 3168, Australia
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Craxford S, Bayley E, Walsh M, Clamp J, Boszczyk BM, Stokes OM. Missed cervical spine injuries: a national survey of the practice of evaluation of the cervical spine in confused and comatose patients. Bone Joint J 2017; 98-B:825-8. [PMID: 27235527 DOI: 10.1302/0301-620x.98b6.37435] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Accepted: 01/10/2016] [Indexed: 12/11/2022]
Abstract
AIM Identifying cervical spine injuries in confused or comatose patients with multiple injuries provides a diagnostic challenge. Our aim was to investigate the protocols which are used for the clearance of the cervical spine in these patients in English hospitals. PATIENTS AND METHODS All hospitals in England with an Emergency Department were asked about the protocols which they use for assessing the cervical spine. All 22 Major Trauma Centres (MTCs) and 141 of 156 non-MTCs responded (response rate 91.5%). RESULTS Written guidelines were used in 138 hospitals (85%). CT scanning was the first-line investigation in 122 (75%). A normal CT scan was sufficient to clear the cervical spine in 73 (45%). However, 40 (25%) would continue precautions until the patient regained full consciousness. MRI was performed in all confused or comatose patients with a possible cervical spinal injury in 15 (9%). There were variations in the grade and speciality of the clinician who had responsibility for deciding when to discontinue precautions. A total of 31 (19%) reported at least one missed cervical spinal injury following discontinuation of spinal precautions within the last five years. Only 93 (57%) had a formal mechanism for reviewing missed injuries. TAKE HOME MESSAGE There are significant variations in protocols and practices for the clearance of the cervical spine in multiply injured patients in acute hospitals in England. The establishment of trauma networks should be taken as an opportunity to further standardise trauma care. Cite this article: Bone Joint J 2016;98-B:825-8.
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Affiliation(s)
- S Craxford
- Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, UK
| | - E Bayley
- Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, UK
| | - M Walsh
- Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, UK
| | - J Clamp
- Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, UK
| | - B M Boszczyk
- Nottingham University Hospitals, Derby Road, Nottingham NG7 2UH, UK
| | - O M Stokes
- Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter EX2 5DW, UK
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Tins BJ. Imaging investigations in Spine Trauma: The value of commonly used imaging modalities and emerging imaging modalities. J Clin Orthop Trauma 2017; 8:107-115. [PMID: 28720986 PMCID: PMC5498756 DOI: 10.1016/j.jcot.2017.06.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 06/03/2017] [Indexed: 10/19/2022] Open
Abstract
Traumatic spine injuries can be devastating for patients affected and for health care professionals if preventable neurological deterioration occurs. This review discusses the imaging options for the diagnosis of spinal trauma. It lays out when imaging is appropriate and when it is not. It discusses strength and weakness of available imaging modalities. Advanced techniques for spinal injury imaging will be explored. The review concludes with a review of imaging protocols adjusted to clinical circumstances.
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Malhotra A, Wu X, Kalra VB, Nardini HKG, Liu R, Abbed KM, Forman HP. Utility of MRI for cervical spine clearance after blunt traumatic injury: a meta-analysis. Eur Radiol 2016; 27:1148-1160. [PMID: 27334017 DOI: 10.1007/s00330-016-4426-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 04/20/2016] [Accepted: 05/20/2016] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To quantify the rate of unstable injuries detected by MRI missed on CT in blunt cervical spine (CS) trauma patients and assess the utility of MRI in CS clearance. METHODS We undertook a systematic review of worldwide evidence across five major medical databases and performed a meta-analysis. Studies were included if they reported the number of unstable injuries or gave enough details for inference. Variables assessed included severity, CT/MRI specifications, imaging timing, and outcome/follow-up. Pooled incidences of unstable injury on follow-up weighted by inverse-of-variance among all included and obtunded or alert patients were reported. RESULTS Of 428 unique citations, 23 proved eligible, with 5,286 patients found, and 16 unstable injuries reported in five studies. The overall pooled incidence is 0.0029 %. Among studies reporting only obtunded patients, the pooled incidence is 0.017 %. In alert patients, the incidence is 0.011 %. All reported positive findings were critically reviewed, and only 11 could be considered truly unstable. CONCLUSIONS There is significant heterogeneity in the literature regarding the use of imaging after a negative CT. The finding rate on MRI for unstable injury is extremely low in obtunded and alert patients. Although MRI is frequently performed, its utility and cost-effectiveness needs further study. KEY POINTS • There were 16 unstable injuries on follow-up MRI among 5286 patients. • The positive finding rate among obtunded patients was 0.12 %. • The positive finding rate among alert, awake patients was 0.72 %. • MRI has a high false-positive rate; its utility mandates further studies. • The use and role of "confirmatory" tests shows wide variations.
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Affiliation(s)
- Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Tompkins East 2, 333 Cedar St, Box 208042, New Haven, CT, 06520-8042, USA.
| | - Xiao Wu
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Tompkins East 2, 333 Cedar St, Box 208042, New Haven, CT, 06520-8042, USA
| | - Vivek B Kalra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Tompkins East 2, 333 Cedar St, Box 208042, New Haven, CT, 06520-8042, USA
| | - Holly K Grossetta Nardini
- Research and Education Librarian, Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, CT, USA
| | - Renu Liu
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Tompkins East 2, 333 Cedar St, Box 208042, New Haven, CT, 06520-8042, USA
| | - Khalid M Abbed
- Minimally Invasive Spine Surgery & Spine Tumor Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Howard P Forman
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Tompkins East 2, 333 Cedar St, Box 208042, New Haven, CT, 06520-8042, USA
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Rajasekaran S, Vaccaro AR, Kanna RM, Schroeder GD, Oner FC, Vialle L, Chapman J, Dvorak M, Fehlings M, Shetty AP, Schnake K, Maheshwaran A, Kandziora F. The value of CT and MRI in the classification and surgical decision-making among spine surgeons in thoracolumbar spinal injuries. 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 2016; 26:1463-1469. [PMID: 27250728 DOI: 10.1007/s00586-016-4623-0] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 05/20/2016] [Accepted: 05/21/2016] [Indexed: 12/25/2022]
Abstract
PURPOSE Although imaging has a major role in evaluation and management of thoracolumbar spinal trauma by spine surgeons, the exact role of computed tomography (CT) and magnetic resonance imaging (MRI) in addition to radiographs for fracture classification and surgical decision-making is unclear. METHODS Spine surgeons (n = 41) from around the world classified 30 thoracolumbar fractures. The cases were presented in a three-step approach: first plain radiographs, followed by CT and MRI images. Surgeons were asked to classify according to the AOSpine classification system and choose management in each of the three steps. RESULTS Surgeons correctly classified 43.4 % of fractures with plain radiographs alone; after, additionally, evaluating CT and MRI images, this percentage increased by further 18.2 and 2.2 %, respectively. AO type A fractures were identified in 51.7 % of fractures with radiographs, while the number of type B fractures increased after CT and MRI. The number of type C fractures diagnosed was constant across the three steps. Agreement between radiographs and CT was fair for A-type (k = 0.31), poor for B-type (k = 0.19), but it was excellent between CT and MRI (k > 0.87). CT and MRI had similar sensitivity in identifying fracture subtypes except that MRI had a higher sensitivity (56.5 %) for B2 fractures (p < 0.001). The need for surgical fixation was deemed present in 72 % based on radiographs alone and increased to 81.7 % with CT images (p < 0.0001). The assessment for need of surgery did not change after an MRI (p = 0.77). CONCLUSION For accurate classification, radiographs alone were insufficient except for C-type injuries. CT is mandatory for accurately classifying thoracolumbar fractures. Though MRI did confer a modest gain in sensitivity in B2 injuries, the study does not support the need for routine MRI in patients for classification, assessing instability or need for surgery.
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Affiliation(s)
| | - Alexander R Vaccaro
- Thomas Jefferson University and the Rothman Institute, Philadelphia, PA, USA
| | - Rishi Mugesh Kanna
- Department of Orthopaedics and Spine Surgery, Ganga Hospital, Coimbatore, India
| | - Gregory D Schroeder
- Thomas Jefferson University and the Rothman Institute, Philadelphia, PA, USA
| | | | | | | | | | | | - Ajoy Prasad Shetty
- Department of Orthopaedics and Spine Surgery, Ganga Hospital, Coimbatore, India
| | | | - Anupama Maheshwaran
- Department of Orthopaedics and Spine Surgery, Ganga Hospital, Coimbatore, India
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Badhiwala JH, Lai CK, Alhazzani W, Farrokhyar F, Nassiri F, Meade M, Mansouri A, Sne N, Aref M, Murty N, Witiw C, Singh S, Yarascavitch B, Reddy K, Almenawer SA. Cervical spine clearance in obtunded patients after blunt traumatic injury: a systematic review. Ann Intern Med 2015; 162:429-37. [PMID: 25775316 DOI: 10.7326/m14-2351] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Cervical spine clearance protocols are controversial for unconscious patients after blunt traumatic injury and negative findings on computed tomography (CT). PURPOSE To review evidence about the utility of different cervical spine clearance protocols in excluding significant cervical spine injury after negative CT results in obtunded adults with blunt traumatic injury. DATA SOURCES MEDLINE, EMBASE, CINAHL, Google Scholar, and the Cochrane Library were searched from January 2000 through November 2014. STUDY SELECTION English-language studies that examined patients with negative CT results having confirmatory routine testing with magnetic resonance imaging (MRI), dynamic radiography, or clinical examination and that reported outcome measures of missed cervical spine injury, need for operative stabilization, or prolonged use of cervical collars. DATA EXTRACTION Independent reviewers evaluated the quality of studies and abstracted the data according to a predefined protocol. DATA SYNTHESIS Of 28 observational studies (3627 patients) that met eligibility criteria, 7 were prospective studies (1686 patients) with low risk of bias and well-interpreted, high-quality CT scans. These 7 studies showed that 0% of significant injuries were missed after negative CT results. The overall studies using confirmatory routine testing with MRI showed incidence rates of 0% to 1.5% for cervical spine instability (16 studies; 1799 patients), 0% to 7.3% for need for operative fixation (17 studies; 1555 patients), and 0% to 29.5% for prolonged collar use (16 studies; 1453 patients). LIMITATIONS Most studies were retrospective. Approaches to management of soft tissue changes with collars varied markedly. CONCLUSION Cervical spine clearance in obtunded adults after blunt traumatic injury with negative results from a well-interpreted, high-quality CT scan is probably a safe and efficient practice. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Jetan H. Badhiwala
- From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Chung K. Lai
- From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Waleed Alhazzani
- From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Forough Farrokhyar
- From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Farshad Nassiri
- From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Maureen Meade
- From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Alireza Mansouri
- From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Niv Sne
- From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mohammed Aref
- From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Naresh Murty
- From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Christopher Witiw
- From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sheila Singh
- From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Blake Yarascavitch
- From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kesava Reddy
- From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Saleh A. Almenawer
- From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas
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Patel MB, Humble SS, Cullinane DC, Day MA, Jawa RS, Devin CJ, Delozier MS, Smith LM, Smith MA, Capella JM, Long AM, Cheng JS, Leath TC, Falck-Ytter Y, Haut ER, Como JJ. Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2015; 78:430-41. [PMID: 25757133 PMCID: PMC4409130 DOI: 10.1097/ta.0000000000000503] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND With the use of the framework advocated by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group, our aims were to perform a systematic review and to develop evidence-based recommendations that may be used to answer the following PICO [Population, Intervention, Comparator, Outcomes] question:In the obtunded adult blunt trauma patient, should cervical collar removal be performed after a negative high-quality cervical spine (C-spine) computed tomography (CT) result alone or after a negative high-quality C-spine CT result combined with adjunct imaging, to reduce peri-clearance events, such as new neurologic change, unstable C-spine injury, stable C-spine injury, need for post-clearance imaging, false-negative CT imaging result on re-review, pressure ulcers, and time to cervical collar clearance? METHODS Our protocol was registered with the PROSPERO international prospective register of systematic reviews on August 23, 2013 (REGISTRATION NUMBER: CRD42013005461). Eligibility criteria consisted of adult blunt trauma patients 16 years or older, who underwent C-spine CT with axial thickness of less than 3 mm and who were obtunded using any definition.Quantitative synthesis via meta-analysis was not possible because of pre-post, partial-cohort, quasi-experimental study design limitations and the consequential incomplete diagnostic accuracy data. RESULTS Of five articles with a total follow-up of 1,017 included subjects, none reported new neurologic changes (paraplegia or quadriplegia) after cervical collar removal. There is a worst-case 9% (161 of 1,718 subjects in 11 studies) cumulative literature incidence of stable injuries and a 91% negative predictive value of no injury, after coupling a negative high-quality C-spine CT result with 1.5-T magnetic resonance imaging, upright x-rays, flexion-extension CT, and/or clinical follow-up. Similarly, there is a best-case 0% (0 of 1,718 subjects in 11 studies) cumulative literature incidence of unstable injuries after negative initial imaging result with a high-quality C-spine CT. CONCLUSION In obtunded adult blunt trauma patients, we conditionally recommend cervical collar removal after a negative high-quality C-spine CT scan result alone. LEVEL OF EVIDENCE Systematic review, level III.
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Affiliation(s)
- Mayur B Patel
- From the Veterans Affairs (VA) Tennessee Valley Healthcare System (M.B.P.), Nashville VA Medical Center; Division of Trauma and Surgical Critical Care (M.B.P., S.S.H., M.A.S., T.C.L.), Department of Surgery, and Department of Neurosurgery (M.B.P., J.S.C.), Section of Surgical Sciences, Department of Radiology and Radiological Sciences (M.A.D.), and Department of Orthopedic Surgery and Rehabilitation (C.J.D.), Vanderbilt University School of Medicine, Nashville; University of Tennessee Health Science Center (M.S.D.), College of Medicine, Memphis; and University General Surgeons (L.M.S.), University of Tennessee Medical Center, Knoxville, Tennessee; Trauma Surgery Section (D.C.C.), Department of Surgery, Marshfield Clinic, Marshfield, Wisconsin; Division of Trauma, Emergency Surgery, and Surgical Critical Care (R.S.J.), Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York; Trauma Service (J.M.C.), University of Pittsburgh Medical Center-Altoona, Altoona, Pennsylvania; Department of Surgery (A.M.L.), Medical Center of Central Georgia, Macon, Georgia; VA Healthcare System of Ohio (Y.F.-Y.), Cleveland VA Medical Center; Division of Gastroenterology (Y.F.-Y.), Department of Medicine, Case Western Reserve University School of Medicine; and Division of Trauma, Critical Care, and Burns (J.J.C.), Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Departments of Surgery, Anesthesiology/Critical Care Medicine, and Emergency Medicine (E.R.H.), Johns Hopkins University School of Medicine, Baltimore, Maryland
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James IA, Moukalled A, Yu E, Tulman DB, Bergese SD, Jones CD, Stawicki SP, Evans DC. A systematic review of the need for MRI for the clearance of cervical spine injury in obtunded blunt trauma patients after normal cervical spine CT. J Emerg Trauma Shock 2014; 7:251-5. [PMID: 25400384 PMCID: PMC4231259 DOI: 10.4103/0974-2700.142611] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 01/14/2014] [Indexed: 01/13/2023] Open
Abstract
Clearance of cervical spine injury (CSI) in the obtunded or comatose blunt trauma patient remains controversial. In patients with unreliable physical examination and no evidence of CSI on computed tomography (CT), magnetic resonance imaging of the cervical spine (CS-MRI) is the typical follow-up study. There is a growing body of evidence suggesting that CS-MRI is unnecessary with negative findings on a multi-detector CT (MDCT) scan. This review article systematically analyzes current literature to address the controversies surrounding clearance of CSI in obtunded blunt trauma patients. A literature search through MEDLINE database was conducted using all databases on the National Center for Biotechnology Information (NCBI) website (www.ncbi.nlm.nih.gov) for keywords: "cervical spine injury," "obtunded," and "MRI." The search was limited to studies published within the last 10 years and with populations of patients older than 18 years old. Eleven studies were included in the analysis yielding data on 1535 patients. CS-MRI detected abnormalities in 256 patients (16.6%). The abnormalities reported on CS-MRI resulted in prolonged rigid c-collar immobilization in 74 patients (4.9%). Eleven patients (0.7%) had unstable injury detected on CS-MRI alone that required surgical intervention. In the obtunded blunt trauma patient with unreliable clinical examination and a normal CT scan, there is still a role for CS-MRI in detecting clinically significant injuries when MRI resources are available. However, when a reliable clinical exam reveals intact gross motor function, CS-MRI may be unnecessary.
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Affiliation(s)
- Iyore Ao James
- Department of Surgery, Division of Trauma, Critical Care and Burn, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ahmad Moukalled
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Elizabeth Yu
- Department of Orthopedics, Division of Spine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - David B Tulman
- School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Sergio D Bergese
- Department of Anesthesiology and Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Christian D Jones
- Department of Surgery, Division of Trauma, Critical Care and Burn, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Stanislaw Pa Stawicki
- Department of Surgery, Division of Trauma, Critical Care and Burn, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - David C Evans
- Department of Surgery, Division of Trauma, Critical Care and Burn, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Comparison of CT and MRI findings for cervical spine clearance in obtunded patients without high impact trauma. Clin Neurol Neurosurg 2014; 120:23-6. [PMID: 24731570 DOI: 10.1016/j.clineuro.2014.02.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 10/12/2013] [Accepted: 02/17/2014] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Cervical spinal injuries occur in 2.0-6.6% of patients after blunt trauma and can have devastating neurological sequelae if left unrecognized. Although there is high quality evidence addressing cervical clearance in asymptomatic and symptomatic awake patients, cervical spine clearance in patients with altered level of alertness (i.e., obtunded patients with Glasgow coma scale (GCS) of 14 or less) following blunt trauma has been a matter of great controversy. Furthermore, there are no data on cervical spine clearance in obtunded patients without high impact trauma and these patients are often treated based on evidence from similar patients with high impact trauma. This retrospective study was conducted on this specific subgroup of patients who were admitted to a neurointensive care unit (NICU) with primary diagnoses of intracranial hemorrhage with history of minor trauma; the objective being to evaluate and compare cervical spinal computed tomography (CT) and magnetic resonance imaging (MRI) findings in this particular group of patients. METHODS Patients with GCS of 14 or less admitted to neruointensive care unit (NICU) at RUSH University Medical Center from 2008 to 2010 with diagnoses of intracranial hemorrhage (surgical or non-surgical) who had reported or presumed fall (i.e., "found down") were queried from the computer data registry. A group of these patients had cervical spine CT and subsequently MRI for clearing the cervical spine and removal of the cervical collar. Medical records of these patients were reviewed for demographics, GCS score and injury specific data and presence or absence of cervical spine injury. RESULTS Eighty-three patients were identified from the computer database. Twenty-eight of these patients had positive findings on both CT and MRI (33.73% - Group I); four patients had a negative CT but had positive findings on follow-up MRI (4.82% - Group II); fifty-one patients had both negative CT and MRI (61.44% - Group III). All patients in Group I required either surgical stabilization or continuation of rigid cervical orthosis. All four patients in Group II had intramedullary T2 hyper intensity consistent with possible spinal cord injury on MRI, but did not have any signs of fracture or ligamentous injury to suggest instability. They eventually underwent surgical decompression of the spinal cord during the same hospital stay. Cervical collars were safely removed in all patients in Group III. In our retrospective study, CT had a sensitivity of 0.875 [0.719-0.950, 95% CI] and a specificity of 1.000 [0.930-1.000, 95% CI] in detecting all cervical spine injuries compared to MRI. However, all patients with missed injuries had intramedullary T2 hyper intensity consistent with possible spinal cord injury on MRI and were not unstable precluding cervical spine clearance. If only unstable injuries are considered, CT had a sensitivity of 1.00 [0.879-1.000, 95% CI] and a specificity is 1.000 [0.935-1.000, 95% CI] compared to MRI in this particular group of patients. CONCLUSION CT is highly sensitive in detecting unstable injuries in obtunded patients with GCS of 14 or less in the absence of high impact trauma. In the absence of high impact trauma, neurosurgeons should be comfortable to discontinue the cervical collar after a negative, high-quality CT in this patient population. In the presence of focal neurological deficits unexplained by associated intracranial injury, an MRI may help diagnose intrinsic spinal cord injuries which necessarily may not be unstable in the presence of a negative CT and does not precludes clearance of cervical spine.
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Sparke A, Voss S, Benger J. The measurement of tissue interface pressures and changes in jugular venous parameters associated with cervical immobilisation devices: a systematic review. Scand J Trauma Resusc Emerg Med 2013; 21:81. [PMID: 24299024 PMCID: PMC4222127 DOI: 10.1186/1757-7241-21-81] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 11/20/2013] [Indexed: 12/30/2022] Open
Abstract
Cervical immobilisation is commonly applied following trauma, particularly blunt head injury, but current methods of immobilisation are associated with significant complications. Semi-rigid disposable cervical collars are known to cause pressure ulcers, and impede effective airway management. These collars may also exacerbate a head injury by increasing intracranial pressure as a result of external compression of the jugular veins. There is a clear imperative to find ways of effectively immobilising the cervical spine whilst minimising complications, and any assessment of existing or new devices should include a standardized approach to the measurement of tissue interface pressures and their effect on jugular venous drainage from the brain. This systematic review summarises the research methods and technologies that have been used to measure tissue interface pressure and assess the jugular vein in the context of cervical immobilisation devices. 27 papers were included and assessed for quality. Laboratory investigations and biomechanical studies have gradually given way to methods that more accurately reflect clinical care. There are numerous accounts of skin ulceration associated with cervical collars, but no standardised approach to measuring tissue interface pressure. It is therefore difficult to compare studies and devices, but a pressure of less than 30 mmHg appears desirable. Cervical collars have been shown to have a compressive effect on the jugular veins, but it is not yet certain that this is the cause of the increased intracranial pressure observed in association with cervical collar use. This is the first review of its type. It will help guide further research in this area of trauma care, and the development and testing of new cervical immobilisation devices.
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Affiliation(s)
| | - Sarah Voss
- Research Fellow in Emergency Care, Faculty of Health and Life Sciences, University of the West of England, Bristol, UK.
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Fisher BM, Cowles S, Matulich JR, Evanson BG, Vega D, Dissanaike S. Is magnetic resonance imaging in addition to a computed tomographic scan necessary to identify clinically significant cervical spine injuries in obtunded blunt trauma patients? Am J Surg 2013; 206:987-93; discussion 993-4. [DOI: 10.1016/j.amjsurg.2013.08.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2013] [Revised: 08/28/2013] [Accepted: 08/29/2013] [Indexed: 11/25/2022]
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Kanji HD, Neitzel A, Sekhon M, McCallum J, Griesdale DE. Sixty-four-slice computed tomographic scanner to clear traumatic cervical spine injury: systematic review of the literature. J Crit Care 2013; 29:314.e9-13. [PMID: 24393410 DOI: 10.1016/j.jcrc.2013.10.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 10/06/2013] [Accepted: 10/25/2013] [Indexed: 11/17/2022]
Abstract
PURPOSE Cervical spine (CS) injury in blunt trauma is a prevalent and devastating complication. Clearing CS injuries in obtunded patients is fraught with challenges, and no single imaging modality or algorithm is both safe and effective. Increased time in c-spine precautions is associated with greater patient morbidity including increased ventilator associated pneumonia, delirium and ulceration. We systemically reviewed the literature to assess the effectiveness of 64-slice computed tomographic (CT) scanners in clearing traumatic CS injuries. MATERIALS AND METHODS Studies were identified using MEDLINE and Embase, the references of identified studies, international experts on CS clearance and authors of primary studies. Three reviewers independently selected and extracted data from studies that reported on both CT and MRI in traumatic CS injury. RESULTS We included five studies involving a total of 3443 patients; however, heterogeneity and lack of sample size precluded quantitative summation of the results. Qualitative assessment showed that 64-Slice CT scan, when applied within a set protocol, performed favourably in clearing injury. CONCLUSIONS Data suggests that using 64-slice CT scans on obtunded trauma patients with grossly intact motor function, in the context of a defined clearance protocol with interpretation by an experienced radiologist, may be sufficient to safely clear significant CS injury. A prospective study comparing MRI and 64-slice CT scan clearance in this population is necessary to corroborate these conclusions.
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Affiliation(s)
- Hussein D Kanji
- Department of Medicine, Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada; Department of Emergency Medicine, Fraser Health Region, New Westminster, BC, Canada.
| | - Andrew Neitzel
- Department of Medicine, Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Mypinder Sekhon
- Department of Medicine, Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jessica McCallum
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Donald E Griesdale
- Department of Medicine, Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada; Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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Mezue WC, Onyia E, Illoabachie IC, Chikani MC, Ohaegbulam SC. Care related and transit neuronal injuries after cervical spine trauma: state of care and practice in Nigeria. J Neurotrauma 2013; 30:1602-7. [PMID: 23758277 DOI: 10.1089/neu.2012.2795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Suboptimal care during extraction and transfer after spinal trauma predisposes patients to additional spinal cord injury. This study examines the factors that contribute to care related and transit injuries and suggests steps to improve standard of care in spinal trauma patients in Nigeria. It is a questionnaire-based prospective study of patients admitted with cervical cord injury to two neurosurgical centers in Enugu, Nigeria, between March 2008 and October 2010. Demography, mechanism of injury, mode of extraction from the scene and transportation to first visited hospital, precautions taken during transportation, and treatment received before arriving at the neurosurgical unit were analyzed. There were 53 (77.9%) males, the mean age was 33.9 years, and 23.5% had concomitant head injury. Average delay was 3.5 h between trauma and presentation to initial care and 10.4 days before presentation to definitive care. Only 26.5% presented primarily to tertiary centers with trauma services. About 94.1% were extracted by passersby. None of the patients received cervical spine protection either during extrication or in the course of transportation to initial care, and 35.3% were sitting in a motor vehicle or supported on a motorbike during transport. Of the 43 patients transported lying down, 41.9% were in the back seat of a sedan, and only 11.8% were transported in an ambulance. Neurological dysfunction was first noticed after removal from the scene by 41.2% of patients, while 7.4% noticed it on the way to or during initial care. During subsequent transfer to definitive centers, only 36% had cervical support, although 78% were transported in ambulances. Ignorance of pre-hospital management of cervically injured patients exists in the general population and even among medical personnel and results in preventable injuries. There is need for urgent training, provision of paramedical services, and public enlightenment.
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Affiliation(s)
- Wilfred C Mezue
- Department of Surgery, University of Nigeria Teaching Hospital, Enugu, Nigeria.
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Chew BG, Swartz C, Quigley MR, Altman DT, Daffner RH, Wilberger JE. Cervical spine clearance in the traumatically injured patient: is multidetector CT scanning sufficient alone? Clinical article. J Neurosurg Spine 2013; 19:576-81. [PMID: 24033302 DOI: 10.3171/2013.8.spine12925] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECT Clearance of the cervical spine in patients who have sustained trauma remains a contentious issue. Clinical examination alone is sufficient in neurologically intact patients without neck pain. Patients with neck pain or those with altered mental status or a depressed level of consciousness require further radiographic evaluation. However, no consensus exists as to the appropriate imaging modality. Some advocate multidetector CT (MDCT) scanning alone, but this has been criticized because MDCT is not sensitive in detecting ligamentous injuries that can often only be identified on MRI. METHODS Patients were identified retrospectively from a prospectively maintained database at a Level I trauma center. All patients admitted between January 2004 and June 2011 who had a cervical MDCT scan interpreted by a board-certified radiologist as being without evidence of acute traumatic injury and who also had a cervical MRI study obtained during the same hospital admission were included. Data collected included patient demographics, mechanism of injury, Glasgow Coma Scale score at the time of MRI, the indication for and findings on MRI, and the number, type, and indication for cervical spine procedures. RESULTS A total of 1004 patients were reviewed, of whom 614 were male, with an overall mean age of 47 years. The indication for MRI was neck pain in 662 patients, altered mental status in 467, and neurological signs or symptoms in 157. The MRI studies were interpreted as normal in 645 patients, evidencing ligamentous injury alone in 125, and showing nonspecific degenerative changes in the remaining patients. Of the 125 patients with ligamentous injuries, 66 (52.8%) had documentation of clearance (29 clinical, 37 with flexion-extension radiographs). Another 32 patients were presumed to be self-cleared, bringing the follow-up rate to 82% (98 of 119). Five patients died prior to clearance, and 1 patient was transferred to another facility prior to clearance. Based on these data, the 95% confidence interval for the assertion that clinically irrelevant ligamentous injury in the face of normal MDCT is 97%-100%. No patient with ligamentous injury on MRI was documented to require a surgical procedure or halo orthosis for instability. Thirty-nine patients ultimately underwent cervical surgical procedures (29 anterior and 10 posterior; 5 delayed) for central cord syndrome (21), quadriparesis (9), or discogenic radicular pain (9). None had an unstable spine. CONCLUSIONS In this study population, MRI did not add any additional information beyond MDCT in identifying unstable cervical spine injuries. Magnetic resonance imaging frequently detected ligamentous injuries, none of which were found to be unstable at the time of detection, during the course of admission, or on follow-up. Magnetic resonance imaging provided beneficial clinical information and guided surgical procedures in patients with neurological deficits or radicular pain. An MDCT study with sagittal and coronal reconstructions negative for acute injury in patients without an abnormal motor examination may be sufficient alone for clearance.
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Cervical spine clearance in trauma patients. INDIAN JOURNAL OF NEUROTRAUMA 2012. [DOI: 10.1016/j.ijnt.2012.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Kaiser ML, Whealon MD, Barrios C, Kong AP, Lekawa ME, Dolich MO. The Current Role of Magnetic Resonance Imaging for Diagnosing Cervical Spine Injury in Blunt Trauma Patients with Negative Computed Tomography Scan. Am Surg 2012; 78:1156-60. [DOI: 10.1177/000313481207801032] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Clearance of cervical spine (CS) precautions in the neurologically altered blunt trauma patient can be difficult. Physical examination is not reliable, and although computed tomography (CT) may reveal no evidence of fracture, it is generally believed to be an inferior modality for assessing ligamentous and cord injuries. However, magnetic resonance imaging (MRI) is expensive and may be risky in critically ill patients. Conversely, prolonged rigid collar use is associated with pressure ulceration and other complications. Multidetector CT raises the possibility of clearing CS on the basis of CT alone. We performed a retrospective review at our Level I trauma center of all blunt trauma patients with Glasgow Coma Scale Score 14 or less who underwent both CT and MRI CS with negative CT. One hundred fourteen patients met inclusion criteria, of which 23 had MRI findings. Seven (6%) of these had neurologic deficits and/or a change in management on the basis of MRI findings. Although use of the single-slice scanner was significantly associated with MRI findings (odds ratio, 2.62; P = 0.023), no significant clinical risk factors were identified. Patients with MRI findings were heterogeneous in terms of age, mechanism, and Injury Severity Score. We conclude that CS MRI continues play a vital role in the workup of neurologically altered patients.
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Affiliation(s)
- Meghann L. Kaiser
- Department of Surgery, University of California, Irvine, School of Medicine, Orange, California
| | - Matthew D. Whealon
- Department of Surgery, University of California, Irvine, School of Medicine, Orange, California
| | - Cristobal Barrios
- Department of Surgery, University of California, Irvine, School of Medicine, Orange, California
| | - Allen P. Kong
- Department of Surgery, University of California, Irvine, School of Medicine, Orange, California
| | - Michael E. Lekawa
- Department of Surgery, University of California, Irvine, School of Medicine, Orange, California
| | - Matthew O. Dolich
- Department of Surgery, University of California, Irvine, School of Medicine, Orange, California
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Lemkin DL, Bond MC, Brady WJ. The orthopedic literature 2011. Am J Emerg Med 2012; 30:1296-305. [DOI: 10.1016/j.ajem.2012.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Revised: 04/07/2012] [Accepted: 04/14/2012] [Indexed: 11/30/2022] Open
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Gebauer G, Osterman M, Harrop J, Vaccaro A. Spinal cord injury resulting from injury missed on CT scan: the danger of relying on CT alone for collar removal. Clin Orthop Relat Res 2012; 470:1652-7. [PMID: 22395870 PMCID: PMC3348314 DOI: 10.1007/s11999-012-2286-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Strict criteria have been used before removing cervical collars in patients with injuries who have midline pain or are unable to be reliably examined. This sometimes leads to prolonged immobilization in cervical collars or use of MRI to rule out injury. Several studies suggest a collar may be removed in the absence of fractures, dislocation, or pathologic subluxation on a cervical CT scan. This may avoid the morbidity of prolonged cervical immobilization or cost of advanced imaging study but risks devastating consequences from missing injuries. CASE DESCRIPTION We report a patient with a cervical spinal cord injury after removal of a collar after a CT scan was misinterpreted as normal. Retrospective review of the CT showed subtle signs of widening between the spinous processes of the injured level, a finding easily missed without the use of further imaging studies. LITERATURE REVIEW Several articles suggest cervical collars may be safely removed from awake and alert patients and in patients who cannot be reliably examined after a negative CT scan without the need for further imaging. PURPOSES AND CLINICAL RELEVANCE CT scans are excellent at detecting bony injuries but not ligamentous injuries. Removing cervical collars based on CT scans alone may be expeditious, but some injuries may be missed without further imaging. Our case demonstrates the catastrophic consequences of missing a cervical spine injury and emphasizes the need for maintaining the cervical collar in high-risk patients until proper imaging can be obtained.
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Affiliation(s)
- Gregory Gebauer
- Advanced Orthopedic Center, 1641 Tamaimi Trail, Suite 1, Port Charlotte, FL 33948 USA
| | - Meredith Osterman
- Department of Orthopedics, Thomas Jefferson University, Philadelphia, PA USA
| | - James Harrop
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA USA
| | - Alexander Vaccaro
- Department of Orthopedics, Thomas Jefferson University, Philadelphia, PA USA
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van Middendorp JJ, Schuetz M. Likelihood of Tetraplegia after CT Clearance of the Cervical Spine in Obtunded Blunt Trauma Patients. J Neurotrauma 2012; 29:1714-5. [DOI: 10.1089/neu.2011.1965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Joost J. van Middendorp
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Queensland, Australia
- Trauma Service, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Michael Schuetz
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Queensland, Australia
- Trauma Service, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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The pediatric cervical spine instability study. A pilot study assessing the prognostic value of four imaging modalities in clearing the cervical spine for children with severe traumatic injuries. Childs Nerv Syst 2012; 28:699-705. [PMID: 22290498 DOI: 10.1007/s00381-012-1696-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Accepted: 01/10/2012] [Indexed: 12/31/2022]
Abstract
PURPOSE Cervical spine clearance in severely injured children after trauma is often difficult because of unique injury patterns, concerns about radiation exposure to growing tissue, and unfamiliarity with unstable cervical injuries. We prospectively assessed the utility of four radiographic modalities to clear the cervical spine in children after severe trauma. METHODS Twenty-four comatose, intubated children with severe traumatic injuries underwent radiographic evaluation to clear the cervical spine. Each patient had plain radiographs, flexion-extension radiographs under fluoroscopy, computed tomography (CT), and magnetic resonance (MR) imaging within 10 days of admission. Patients underwent cervical spine flexion-extension radiographs 2-3 months after trauma to detect late instability. Sensitivity and specificity for each radiographic modality was determined. RESULTS Plain cervical spine radiographs demonstrated sensitivity of 100% and specificity of 95%; flexion-extension radiographs had “indeterminate” sensitivity and specificity of 100%. For CT, sensitivity was 100% and specificity was 95%, and for MR imaging, sensitivity was 100% and specificity was 74%. CONCLUSIONS There was a low prevalence of cervical instability in this high-risk group. Plain radiographs, flexion-extension radiographs, and CT all had high sensitivities and specificities. MR imaging had a high false-positive rate, making it sensitive but not specific. The data support using either CT or plain radiographs as the initial cervical spine screening study, but CT is recommended because of its superior ability to detect critical injuries. To definitively rule out ligamentous instability after a negative screening CT scan or cervical spine X-ray, these data support using flexion-extension X-rays with fluoroscopy and not MR imaging.
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Clinical review: Spinal imaging for the adult obtunded blunt trauma patient: update from 2004. Intensive Care Med 2012; 38:752-71. [PMID: 22407141 DOI: 10.1007/s00134-012-2485-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Accepted: 12/13/2011] [Indexed: 12/22/2022]
Abstract
PURPOSE Controversy exists over how to 'clear' (we mean enable the clinician to safely remove spinal precautions based on imaging and/or clinical examination) the spine of significant unstable injury among clinically unevaluable obtunded blunt trauma patients (OBTPs). This review provides a clinically relevant update of the available evidence since our last review and practice recommendations in 2004. METHODS Medline, Embase. Google Scholar, BestBETs, the trip database, BMJ clinical evidence and the Cochrane library were searched. Bibliographies of relevant studies were reviewed. RESULTS Plain radiography has low sensitivity for detecting unstable spinal injuries in OBTPs whereas multidetector-row computerised tomography (MDCT) approaches 100%. Magnetic resonance imaging (MRI) is inferior to MDCT for detecting bony injury but superior for detecting soft tissue injury with a sensitivity approaching 100%, although 40% of such injuries may be stable and 'false positive'. For studies comparing MDCT with MRI for OBTPs; MRI following 'normal' CT may detect up to 7.5% missed injuries with an operative fixation in 0.29% and prolonged collar application in 4.3%. Increasing data is available on the complications associated with prolonged spinal immobilisation among a population where a minority have an actual injury. CONCLUSIONS Given the variability of screening performance it remains acceptable for clinicians to clear the spine of OBTPs using MDCT alone or MDCT followed by MRI, with implications to either approach. Ongoing research is needed and suggestions are made regarding this. It is essential clinicians and institutions audit their data to determine their likely screening performances in practice.
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Horodyski M, DiPaola CP, Conrad BP, Rechtine GR. Cervical Collars are Insufficient for Immobilizing an Unstable Cervical Spine Injury. J Emerg Med 2011; 41:513-9. [DOI: 10.1016/j.jemermed.2011.02.001] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2010] [Revised: 06/08/2010] [Accepted: 02/13/2011] [Indexed: 10/18/2022]
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