Evidence-based imaging evaluation of the cervical spine in trauma
Section snippets
Evidence-based analysis and literature review
A MEDLINE search was performed using PubMed (National Library of Medicine, Bethesda, MD) for original research publications discussing the diagnostic performance and effectiveness of imaging strategies for the cervical spine. Clinical predictors of cervical spine fracture were also included in the literature search. The search covered the years 1966 to March 2002. The search strategy employed different combinations of the following terms: (1) cervical spine, (2) radiography OR imaging OR
Epidemiology
Cervical spine fractures occur in approximately 10,000 individuals per year in the United States, most the result of blunt trauma [3], [4]. Among patients with a fracture, approximately one in three sustain severe neurologic injury [3], [5]. Unfortunately, fractures of the cervical spine may not be clinically obvious. Patients may be neurologically intact initially but, if not treated appropriately and promptly, may progress to severe neurologic compromise [6]. Delayed onset of paralysis occurs
Selection of subjects for imaging
The low yield of cervical imaging has prompted several investigators to attempt to identify clinical factors that could be used to predict cervical spine fracture. Early studies of this question were largely level 3 investigations consisting of unselected case series. In 1988, Roberge and colleagues [21] studied 467 consecutive subjects who underwent cervical spine radiography and found that subjects with cervical discomfort or tenderness were more likely to have a fracture than were subjects
Selection of imaging strategy
In subjects in whom imaging is appropriate, the next issue is determination of what imaging modality should be used. For decades, the standard imaging protocol for the cervical spine in trauma patients has been radiography; however, more recently, CT has been proposed as an alternate imaging strategy, particularly in subjects who are also scheduled to undergo head CT.
Summary
Despite the relatively low frequency of cervical spine fractures in trauma patients, tremendous resources are expended on the use of imaging to exclude fracture. Some level 2 evidence can direct the selection of subjects for imaging and optimization of the imaging strategy. A suggested algorithm for evidence-based cervical spine imaging is shown in Fig. 1. This algorithm is based on the sequential assessment of two questions: (1) Is imaging necessary? (2) If imaging is necessary, what is the
References (52)
- et al.
Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS)
Ann Emerg Med
(1998) - et al.
Low-risk criteria for cervical-spine radiography in blunt trauma: a prospective study
Ann Emerg Med
(1992) - et al.
High-yield roentgenographic criteria for cervical spine injuries
Ann Emerg Med
(1987) - et al.
Prospective analysis of acute cervical spine injury: a methodology to predict injury
Ann Emerg Med
(1986) - et al.
Interrater reliability of cervical spine injury criteria in patients with blunt trauma
Ann Emerg Med
(1998) - et al.
Methodologic standards for the development of clinical decision rules in emergency medicine
Ann Emerg Med
(1999) - et al.
Characteristics of pediatric cervical spine injuries
J Pediatr Surg
(2001) - et al.
Rational ordering of cervical spine radiographs following trauma
Ann Emerg Med
(1988) - et al.
Accuracy of standard radiographic views in detecting cervical spine fractures
Ann Emerg Med
(1983) - et al.
Users' guide to the medical literature. XXV. Evidence-based medicine: principles for applying the users' guides to patient care
JAMA
(2000)
Incidence of acute traumatic hospitalized spinal cord injury in the United States, 1970–1977
Am J Epidemiol
Spinal cord injury: an epidemiologic perspective
Paraplegia
Fractures and dislocations of the cervical spine: an end-result study
J Bone Joint Surg
The etiology of missed cervical spine injuries
J Trauma
Delayed diagnosis of cervical spine injuries
J Trauma
Etiology and clinical course of missed spine fractures
J Trauma
Trends in spinal cord injury demographics and treatment outcomes between 1973 and 1986
Arch Phys Med Rehabil
The National Head and Spinal Cord Injury Survey: major findings
J Neurosurg
Cervical spine imaging in patients with trauma: determination of fracture risk to optimize use
Radiology
Cervical spine injuries in patients 65 years old and older: epidemiological analysis regarding the effects of age and injury mechanism on distribution, type, and stability of injury
AJR Am J Roentgenol
Variability in the practice of emergency radiology
Emergency Radiology
Evaluation of the cervical spine in the polytrauma patient
Spine
Protocol-driven radiologic evaluation of suspected cervical spine injury: efficacy study
Radiology
Reliability of indications for cervical spine films in trauma patients
J Trauma
Variation in emergency department use of cervical spine radiography for alert, stable trauma patients
Can Med Assoc J
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2003, European Journal of RadiologyAccuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: A systematic review
2012, CMAJ. Canadian Medical Association JournalCitation Excerpt :This suggests that the diagnostic accuracy of the Canadian C-spine rule is superior when the rule is used in its entirety. The findings of this review are consistent with a previous meta-analysis14 and 2 literature reviews.30,31 However, our review used a larger and more sensitive search strategy, which resulted in a larger number of primary studies identified for inclusion.
External Validation of University of Wisconsin's Clinical Criteria for Obtaining Maxillofacial Computed Tomography in Trauma
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