Interrater Reliability of Cervical Spine Injury Criteria in Patients With Blunt Trauma,☆☆,

Presented at the Society for Academic Emergency Medicine Annual Meeting, Denver, CO, May 1996.
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Abstract

Study objective:To determine the interrater reliability of previously defined risk criteria for cervical spine injury. Methods: Two emergency physicians independently evaluated patients with blunt trauma to determine whether they exhibited any of four risk criteria: (1) altered neurologic function; (2) evidence of intoxication; (3) spinous process or posterior midline cervical tenderness; or (4) distracting painful injury. Each criterion was explicitly described on study data forms. Physician concordance was measured, and the κ statistic was calculated, for the combined risk criteria (based on the presence of any individual criterion), and for each individual criterion. Results: There were 122 patients evaluated. Physicians agreed on overall classifications for 107 patients (87.7%; κ, .73; confidence interval [CI], .61 to .86). Agreement for individual criteria were as follows: (1) altered neurologic function–102 patients (83.6%; κ, .58; CI, .41 to .74); (2) intoxication–118 patients (96.7%; κ, .86; CI, .72 to .99); (3) posterior midline tenderness–109 patients (89.3%; κ, .77; CI, .65 to .89); (4) distracting injury–112 patients (91.8%; κ, .77; CI, .64 to .91). Conclusion: The combined cervical spine injury criteria have substantial interrater reliability. Individual criteria are slightly less reliable. [Mahadevan S, Mower WR, Hoffman JR, Peeples N, Goldberg W, Sonner R: Interrater reliability of cervical spine injury criteria in patients with blunt trauma. Ann Emerg Med February 1998;31:197-201.]

Introduction

Sporadic case reports of asymptomatic cervical spine injuries1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 have led to the widespread use of radiographic imaging for virtually all persons who present to the emergency department with blunt trauma.13, 14 Such routine imaging detects injuries in a small minority of cases, and subjects 96% to 98% of those with blunt trauma to the risk and expense of negative cervical spine radiography.11, 12, 13, 14

Concerns about the cost and radiation exposure associated with large numbers of negative radiographs have led to the development of “low-risk criteria” designed to screen patients with blunt trauma for cervical spine injury.15 Ideally, such criteria would reliably identify all patients with cervical spine injury (be maximally sensitive) while excluding injury in a large subset of trauma patients (be relatively specific). Previous studies from our institution have suggested that the risk of cervical spine injury is extremely low among patients with blunt trauma if they meet all of the following criteria: (1) they have a normal neurologic function; (2) they are not intoxicated; (3) they have no posterior midline cervical tenderness; and (4) they have no distracting painful injuries.15 In these studies, application of a decision rule that avoids radiography when all four of these criteria are met would have allowed us to decrease the number of radiographic studies by almost one third, while still identifying every patient with cervical spine fracture or dislocation.

The general applicability of any decision rule, however, is critically dependent on whether its elements can be reliably interpreted by different physicians. No prior study has addressed the question of whether clinicians can agree on either the individual low-risk criteria noted or the overall classification of individual patients based on the combined criteria. Given the absence of any prior information on which to base a precise hypothesis, we designed this study to determine the interrater reliability of these criteria among emergency physicians, both as a whole and for each of the individual components.

Section snippets

Methods

This study was conducted between July 1995 and April 1996 in the EDs of a private university hospital and a public county hospital which share an emergency medicine residency program and are staffed by full-time emergency medicine faculty and residents. On presentation, each patient underwent evaluation by one of the residents or attending emergency physicians normally staffing the ED. A second examination was independently performed by one of five emergency physicians involved in the study.

Results

A total of 122 survey pairs were collected during the study period. There were 56 men and 66 women. Their ages ranged between 4 and 95 years; the median age was 32, and there were 7 patients younger than 18 and 17 patients older than 60 years of age. The time between examinations ranged from 1 to 237 minutes, with a median time of 10 minutes; only three paired examinations were done more than 1 hour apart.

Table 1 lists the κ statistics and standard errors for each of the individual criteria and

Discussion

In our previous work, the risk criteria evaluated in this study exhibited a negative predictive value of 100% (with a lower 95% confidence level of 98.7%). In that series, 353 of 974 blunt trauma victims were classified as “risk-free” and could potentially have been safely evaluated without radiography.15 A multicenter study to validate these criteria and define narrow confidence intervals for their sensitivity is currently underway.

The value of any such criteria would be limited, however, if

References (19)

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From the UCLA Emergency Medicine Center and the Department of Medicine, University of California at Los Angeles School of Medicine, Los Angeles, CA.

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Reprint no. 47/1/87766

Address for reprints: William R Mower, MD UCLA Emergency Medicine Center 924 Westwood Boulevard, Suite 300 Los Angeles, California 90024 310-825-7209 Fax 310-794-9747 E-mail [email protected]

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